The medicalisation of sadness, the safety and efficacy of antidepressants, and the relationship between antidepressant use and suicide, are undoubtedly among the most significant mental health controversies within Australia and globally.

 

Antidepressant Use - Since at least 2000, we have been among the world’s biggest users of antidepressant. Between 1 July 2020 and 30 June 2021, more than 3.5 million Australians of all ages (13.0%) were prescribed an antidepressant.[1]

 

Childhood depression - 137,111 Australian children (aged 0-17 years) were dispensed an antidepressant in 2020/21.[2] Through the COVID pandemic. Antidepressant use rates have grown substantially, especially among young Australians. This is despite the fact that no antidepressant is approved by the TGA for the treatment of childhood depression and all antidepressants carry warnings that they increase the risk of suicidal thoughts and behaviours in depressed people aged under 25 years. Since 2008, the per-capita rates of the use of antidepressants and suicide and self-harm among young Australians have all risen alarmingly, raising concerns that the warnings have been ignored and young people have died as a result.

 

Who Prescribes - The vast majority of Australian antidepressant prescribing is done by general practitioners. Some critics contend that GPs lack the depth of mental health training of psychiatrists and psychologists. They contend that this, and other social and economic factors, that have resulted in an increasingly medicalised response to human suffering.

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Safety and Efficacy of Antidepressants - There are growing concerns about both the efficacy and safety of antidepressants, and their withdrawal effects. Until recently, the dominant theory justifying the use of antidepressants, was that depression was caused by a ‘chemical balance’ involving serotonin. However, this theory has been discredited with many of the proponents and organisations (including the RANZCP) that claimed that antidepressants rebalanced brain chemistry, reluctantly acknowledging it this is wrong.

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Other facts about depression and antidepressant use in Australia

• Among those aged 65 and over, antidepressants are often "used to treat... anxiety disorders, chronic pain and some types of urinary incontinence".[3]

• Although antidepressant prescribing rates are much lower among younger Australians they are rising rapidly among young Australians. Between 2012-13 and 2017-18, they grew faster among children (+36%) than any other age group (all ages +10%).

• In 2004 the US Food and Drug Administration (FDA) issued a black box warning (the highest level of warning) that using antidepressants is associated with an increased risk of suicidal thinking and behaviour in people under 25 years of age with depression and other psychiatric disorders.  Shortly after in response to the FDA’s black box warning, the Australian Therapeutic Goods Administration (TGA) required the rewording of Product Information and Consumer Information leaflets made available to doctors and consumers to highlight the increased suicidality risk for under 25’s.

• The first Australian Atlas of Healthcare Variation, published in 2015, suggested that, for children, antidepressants are “primarily prescribed for anxiety, rather than depression”.[4]

• The Atlas also revealed that there are massive geographical variations in antidepressant prescribing rates.[5}

• Our propensity for using antidepressants is consistent with a 2017 World Health Organization (WHO) publication that reported Australia was the equal 2nd most depressed country in the world.[6] However, Australians (based on self-assessment) are consistently ranked near the top of the world happiness rankings (11th of 185 countries in 2019). The five largest Australian cities are all ranked in the 22 most liveable cities in the world. 

• Most antidepressant prescribing in Australia is done by time-poor GPs with limited mental health training and few other options[7] The average GP consultation lasts just under 15 minutes with just over one medication prescribed per consultation.[8]

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How is depression diagnosed in Australia?  The DSM-5 diagnostic criteria for depression are available by clicking here. Since it was published by the American Psychiatric Association in 2013, DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders 5th edition) has been adopted by the Australian medical and psychiatric profession as the model for diagnosing depression and other psychiatric disorders. This was done without adequate consideration of how it would impact on the well-being of Australian mental health consumers.

 

The same lack of scrutiny occurred when the previous version, DSM-IV was published in 1994. DSM-5 expanded the diagnostic boundaries for many psychiatric disorders. As a result, people who (before DSM-5) were classified as essentially well now qualify for a diagnosis of a psychiatric disorder. For example, DSM-IV required that following the death of a loved one the symptoms of major depressive disorder last more than 2 months, whereas DSM-5 only requires the symptoms to last for at least two weeks. Each successive version of the DSM has involved similar 'diagnostic creep' (loosening of diagnostic criteria or adding new disorders).

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References

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[1] Table PBS.2: Number of patients dispensed one or more mental health-related medications, by type of medication prescribed and prescribing medical practitioner, states and territories, 2020–21 Available at https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions#data

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[2] Table PBS.5: Number of patients dispensed one or more mental health-related medications, by type of medication prescribed, sex and age group, 2020–21 Available at https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions#data

Although Australians rank highly in global happiness ratings, since at least 2000, we have been among the world’s biggest users of antidepressant. Between 1 July 2020 and 30 June 2021, more than 3.5 million Australians of all ages (13.0%) were prescribed an antidepressant. This included well over 100,000 Australian children (aged 0-17 years). Through the COVID pandemic, these numbers have grown substantially, especially among young Australians.

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[3] Australian Commission on Safety and Quality in Healthcare (ACSQHC), Website of the First Australian Atlas of Healthcare Variation 2015, Section 4 Interventions for mental health and psychotropic medicines Subsection 4.4 Antidepressant medicines dispensing 65 years and over. Available at https://acsqhc.maps.arcgis.com/apps/MapJournal/index.html?appid=398ebb592c0a40cf913814bd7b965546# (accessed 15 April 2019)

 

[4] ACSQHC, Website of the First Australian Atlas of Healthcare Variation 2015, Section 4 Interventions for mental health and psychotropic medicines Subsection 4.2 Antidepressant medicines dispensing 17 years and under. Available at http://acsqhc.maps.arcgis.com/apps/MapJournal/index.html?appid=398ebb592c0a40cf913814bd7b965546# (accessed 15 April 2019)

 

[5] ACSQHC, Website of the First Australian Atlas of Healthcare Variation 2015, Section 4 Interventions for mental health and psychotropic medicines Subsection 4.2 Antidepressant medicines dispensing 17 years and under. Available at http://acsqhc.maps.arcgis.com/apps/MapJournal/index.html?appid=398ebb592c0a40cf913814bd7b965546# (accessed 15 April 2019)

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[6] Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO Available at https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=4C3AC0DC58EEAF097117E33D3C9F4513?sequence=1 (accessed 16 April 2019)

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[7] In 2014/15, the vast majority (90.4%) of antidepressant prescribing was done by general practitioners. Psychiatrists were directly responsible for only 6.5%. Australian Institute of Health and Welfare 2016. Mental health services—in brief 2016. Cat. no. HSE 180 Canberra: AIHW. pp. 24-25 Available at https://www.aihw.gov.au/getmedia/681f0689-8360-4116-b1cc-9d2276b65703/20299.pdf.aspx?inline=true (accessed 13 August 2018)

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[8] "For an ‘average’ 100 GP-patient encounters, GPs provided 102 medications and 39 clinical treatments (such as advice and counselling), undertook 18 procedures, made 10 referrals to medical specialists and 6 to allied health services, and placed 48 pathology test orders and 11 imaging test orders (Table 5.1)." Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Pan Y, Charles J, Pollack AJ, Wong C, Gordon J. General practice activity in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press, 2016, p.34

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