Depression, Antidepressants and Suicide

This page is in development.  Over coming months more material will be added. Until then we hope you find the information below useful.

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Australian Rates of Antidepressant Use - As detailed in Table 1 in our 23 April 2019 blog, approximately 1 in 8 (over 3 million) Australians were prescribed an antidepressant between July 2017 and June 2018.  Table 1 also demonstrates increasing prescribing rates from 2012-13 to 2017-18, particularly for children (0-17), with the percentage of children on antidepressants increasing from 1.3% to 1.8% over this period. It is also very notable that an extraordinarily high proportion (over 1 in 4) of elderly Australians (aged over 78 years) that took antidepressants.

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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".[1]

• Antidepressant prescribing rates are much lower among younger Australians. However, between 2012-13 and 2017-18, they grew faster among children (+36%) than any other age group (all ages +10%).

• In Australia, no antidepressant is approved for use by a patient under 18 years of age.

• 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”.[2]

• The Atlas also revealed that there are massive geographical variations in antidepressant prescribing rates.[3]

• 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.[4] 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[5] The average GP consultation lasts just under 15 minutes with just over one medication prescribed per consultation.[6]

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How is depression diagnosed in Australia?  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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Major Depressive Disorder Diagnostic Criteria

from DSM5 (the Diagnostic and Statistical Manual of Mental Disorders 5th edition)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.

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1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

 

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

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Note: Criteria A–C represent a major depressive episode.

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Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

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D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

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E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance induced or are attributable to the physiological effects of another medical condition.

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References

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[1] 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)

 

[2] 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)

 

[3] 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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[4] 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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[5] 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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[6] "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