Opinion Research — 11 December 2014

“Jessica Edward.” The nurse finally called my name. One more minute in the  campus medical centre and I was sure to contract something nasty.

The centre is a place to be avoided at all costs. All year, the four-metre-square coffin is packed with sick students, herded one by one by whichever French-manicured receptionist is scheduled on that day.

I made my way through the sweatpant-clad bodies, past the health and education posters. A quick glance at one of those is enough to instil a deep-seated neurosis. (I really don’t wash my hands enough, do I?)

My doctor wasn’t here for tea and biscuits. As soon as my nether regions hit  the still-warm seat, I was asked, “What can I do for you today, Jessica?”

I began my spiel, one all too many students have regurgitated to get that doctor’s certificate for an extension.

“Look, I haven’t slept in two days. I just can’t fall asleep. Assignments are stacking up and I just can’t handle it. I don’t know what do to. I think I just need to break the cycle with some sleeping pills.”

On cue, fat tears roll down my cheeks, smearing the mascara I had coated on thickly to hide the dark circles framing my eyes. Soon the tears were accompanied by gasps for breath. You can only understand the overwhelming importance of sleep when you have none at all.

The doctor looked at me with a calm and authoritative glance. Surely hysterical students were common here.

“I think what we need to do is start you on is some antidepressants, and get you to a psychologist. You obviously have some underlying issues you need to address.”Beers Criteria

I was stunned, silenced. Underlying issues?

“What? Surely not. I am not depressed am I? I’m just really, really tired.”

Within minutes I was ushered out of the medico’s office, feeling confused and misunderstood, clutching a prescription for Prozac and the number of a local psychologist.

The OECD’s 2013 Health at a Glance report ranks Australians as the second-highest users of antidepressant medications out of 33 nations, with 89 per 1000 people taking them..

Australia’s consumption is surpassed only by Iceland’s, with 106 in 1000 people using antidepressants. And between 2000 and 2011, our use doubled, raising concerns about overprescription.

According to the OECD, increased use can be explained by longer duration of  treatment and the extension of their use to milder forms of depression, general anxiety disorders and social phobias, “raising concerns”, as the report states, “about appropriateness”.

Australian Public Health Association chief executive Michael Moore says: “What I am concerned about is that there is an expectation. I often hear parents saying ‘What I want for my children is to be happy’ and I actually think it is a completely unrealistic expectation. What you really want for your children is to be content, to understand there are times where they are very happy and there are times, even for sustained periods, where they are quite sad. And that is very different from people who do have serious problems with depression.

“But we do have to be careful that we don’t swing the pendulum too far, so that people who do have depression are not getting treated. We do want them to be treated and the earlier, the more effective the treatment.”

Stress factors stack up for university students: late nights, deadlines, financial stresses, new relationships, heavy alcohol consumption, unhealthy eating. These factors coincide with the existential angst that twentysomethings commonly face. “Who am I?” “Where do I belong?” “How am I going to make a living with an arts degree?”

Associate professor and Beyond Blue board director Michael Baigent says: “University students, these days particularly, are often under a lot of pressure and stress – financial firstly, and secondly a lot of university students travel to other places away from their family and support systems. They are also going through a prolonged period of valuations and examinations which is a fairly unique time in your life … So, certainly psychological approaches can benefit university students.”

According to Youth Beyond Blue, a support group for young people experiencing depression, one in 16 Australians between 16 and 24 have experienced depression in the past 12 months.

Youth suicide is the third-most common cause of death in that age group.

There is also evidence indicating that depression, like other mental illnesses, is undertreated. A 2009 survey showed only one-third of the people who met criteria for a mental illness made use of mental health services.

A 2010 study concluded that young Australians aged 18-24 had a higher prevalence of mental illness than any other age group. University students are four times more likely to be anxious or depressed than other people their age. The research also found that 48 per cent of participating students from the medicine, law, mechanical engineering, and psychology faculties at the University of Adelaide showed the highest rates of levels of anxiety and depression.

But have we gone too far when a student can get a script for an antidepressant in less than 10 minutes without even asking for it?

Professor Philip Mitchell, head of the University of NSW School of Psychiatry, says one factor causing the dramatic increase in antidepressant consumption is the time pressure on GPs.

“In my experience, most GPs want to give the best treatment to their depressed patients. Nonetheless, antidepressant usage has increased dramatically, suggesting that the time pressures of the average GP session mean that more antidepressant scripts are being written than would be optimal, rather than the GP doing simple counselling, or referring to a psychologist,” Mitchell says.

“It’s finding the right balance, which is always a challenge. Particularly for medical practitioners, who are often treating somebody in a 15-minute interview and are probably taking the precautionary approach. It is better that we overtreat, rather than having people taking their own lives.”

Yet Mitchell does wonder if Australia is moving toward concerning levels of antidepressant overconsumption, underutilising effective alternative treatments, including structured psychological therapies such as cognitive behavioural therapy.

Antidepressants can be very effective for some people and in a particular “type” of depression, and ineffective for others. This “type” of depression is called melancholic depression.

Baigent says: “The best way of thinking about depression is on a spectrum … At one end there is melancholic depression and the other end is very mild depression, which is reactive to stresses or circumstances. When depression is reactive to circumstances, and is milder, certainly antidepressants are not indicated. From what we know from research, antidepressants are effective in the most extreme ends of depression, such as melancholic depression.”

It is important , he adds, “not to medicalise normal unhappiness and sadness, and try treat it with an antidepressant”.

No medication is free of complications. Yet common side effects of antidepressants include difficultly discontinuing it, nausea, insomnia, weight gain and loss of sexual desire.

Prozac was once regarded as a miracle drug, able to make depressed patients “better than well”. But reports soon emerged showing some users of Prozac and other selective serotonin re-uptake inhibitors (SSRIs) becoming uncharacteristically violent and suicidal. The link between Prozac and suicide in children is now well-known, resulting in guidelines to the medical profession that it not be prescribed in those under 16 except as a last resort.

Yet it is undeniable that antidepressants also save lives.

According to the Black Dog Institute, however, melancholic depression is very unlikely to respond to self-help and alternative therapies alone, although these can be valuable adjuncts to physical treatments.

In the past decade, Australia has made huge progress in reducing the negative stigma associated with depression and anxiety. This has vastly improved the diagnosis and treatment of mental illnesses.

Yet, it seems that in the rush to destigmatise, we have lost our understanding of and tolerance for normal adversity.

In my own experience, there was no emphasis on alternative treatment options. My brief patch of insomnia saw me labelled with depression and antidepressants were readily reached for, like Panadol for a headache. This route is by no means inherently wrong; it may well have been the most suitable for my situation.

It does, however, spark concerns over the speed with which these drugs are regarded as the primary option, particularly in students who may or may not understand their full capacity or levels of addictiveness of the drug they are consuming.

It makes one consider David Healy’s argument, in his widely acclaimed book The Antidepressant Era (1995), that antidepressants are a miracle of modern marketing, rather than of modern medicine. It seems so bizarre in an age where superfoods reign supreme, boot camps are a plentiful, and holistic health shops line Paddington’s urban landscape.

Perhaps it is time for some power to be returned to the patient, each of us considering what is the “right” balance between pleasure and pain in our life.

And as for me, I haven’t filled that prescription. But I haven’t thrown it away either …

This article first appeared on ‘WAtoday‘ on 12 December 2014.


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