There has been a transformation in social and scientific attitudes to depression in my working lifetime. It is no longer acceptable to stigmatise mental illness or psychological distress. The idea that the common mental disorders of depression and anxiety are an inescapable part of being human has been replaced by a belief that these disabling extremes of sadness and worry are treatable conditions.
Changes in the treatment of depression have been part of wider cultural changes. There is an increased openness about sadness and distress, and a widespread belief, beginning with Freud, that at the very least ‘neurotic misery can be transformed into ordinary unhappiness’. The invention of psychotherapy has spawned numerous schools and sub-disciplines, but all hold to the common belief that with help, you can talk yourself out of depression. The social impact of this in the United Kingdom has been huge; we have a major state-sponsored programme for Improving Access to Psychological Therapies (IAPT) that has made talking treatments more widely available than ever before at no cost to the individual.
At the same time, it has become an article of faith that brain chemistry can be manipulated and even fixed to improve mental and emotional states. We now believe that drugs are not just for escaping reality; they help us to make reality better by interacting more positively with the world. If there has been a steady growth in the development and provision of psychotherapies, there has been an explosion in the treatment of depression with drugs. This began in the 1970s, but really took off with the development of the Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac. From a few million prescription items per annum in the 1980s the industry has grown and we now issue over 60 million prescriptions for antidepressants each year in England and Wales. We aren’t the only ones; this pattern is replicated throughout the developed world.
Primary care is at the heart of this change in the UK. We manage about 90% of people diagnosed with depression. We prescribe most of the drugs used to treat it. IAPT has been developed as a primary care service and GPs have been counseling and supporting patients with depression all of our working lives. We work at the interface between physical illness and depression, and this is especially important in the growing area of chronic physical illness. Depression is a common ingredient in the multimorbidity that characterizes our ageing population.
In spite of the huge growth in the availability of treatments, there are still surprising gaps in our knowledge and inadequacies in our treatment provision. Our work at the Centre for Academic Primary Care and Centre for Academic Mental Health in Bristol addresses some of these issues. We are currently engaged in a programme of work funded by the National Institute for Health Research (NIHR) to develop a web-based platform that therapists can use to make cognitive behavioural therapy (CBT) more convenient and accessible. Because the programme blends real time psychotherapy with therapist-directed and self-directed use of online materials it has the potential to deliver CBT in a more effective and cost effective way. This work is based on our earlier work into the effectiveness of online psychotherapy.
Treatment resistance is an important and neglected area in depression. More than half of those who take their antidepressants remain depressed, many of them for years. Treatment resistance is under-researched. We have completed large randomised trials in primary care that have tested the effectiveness of both CBT and the addition of a second antidepressant to address this unmet clinical need. We have applied for further funding in partnership with colleagues in University College London for a trial of Transcranial Magnetic Stimulation (TMS) for treatment resistance. This last is a novel intervention with minimal adverse effects that has the potential to deliver substantial benefits to this group of patients.
We are also involved in trials that look at both ends of the natural history of depression. We are nearing the end of a study that aims to establish the threshold for the use of antidepressants in depression, and would provide GPs with some much-needed guidance in this area. This study also looks to describe the minimal clinically important difference that makes treatment worthwhile from a patient perspective. And we are just starting a trial that asks when it is safe to stop antidepressants in those who have recovered. In spite of the plethora of guidelines, we simply do not know the answers to these questions.
I’m not going to attempt to answer the question ‘has all this made us any happier?’ Its impossible to say and it’s the wrong question anyway. The World Health Organization tells us that ‘Depression is the leading cause of ill health and disability worldwide’ and that stigma is still a huge problem, in spite of changing attitudes. At least we’re talking about it.