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Depression: Private trouble to “social problem”?
Introduction
When I glanced at the front page of the Guardian in early March, 2011 and saw a story that suggested that antidepressant prescribing was higher in the north than the south of England(Ball and Boseley, 2011), my first reaction was, “Why is this news?” As a GP I presumed it was common sense that depression is associated with deprivation. On reading further it was clear that the journalists (who had carried out their own analysis on publicly available datasets) acknowledged this relationship. But they had been briefed by the Department of Health and Primary Care Trusts (Boseley and Ball, 2011) that another cause might be that GPs in the north of England were rushing too fast for their prescription pads rather than referring patients for psychological treatments. Since the data was ecological and not about individual patients, there was no way of knowing if prescribing was in line with current guidelines. The presumption is that there is over-prescription of antidepressants in certain areas; along with under-referral to psychological therapies which aim to get people back to work and off benefits. This essay will explore the changing concept of depression and its management over the past 40 years, and suggest that depression has gone from being considered a private trouble with possibly social causes, to its current reframing as a “social problem” which has an individual-level solution.

Changing concepts of depression
Internationally our definitions of psychiatric conditions are determined by two documents: the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD) and the American Psychiatric Association’s Diagnostic and Statistics Manual (DSM). ICD 6 published in 1949 was the first to include psychiatric conditions, and DSM was published for the first time in 1952. Prior to the third version of DSM published in 1980, which contained substantial revision of the criteria for most conditions, depression was a much less common diagnosis than anxiety (Horwitz, 2011). Much confusion surrounded the diagnosis of depression(Kendell, 1976). One division was between reactive/neurotic and endogenous/psychotic depression, which was “at the heart of most of the controversies” of the prior fifty years (Kendell, 1976). During the 1960s and 70s, psychiatry had been under attack from the ‘antipsychiatry’ movement who queried the very existence of the specialty (Moncrieff, 2010, Mayes and Horwitz, 2005, Bracken and Thomas, 2010). Horwitz (2011) describes how during the 1970s there was pressure within the professional field of psychiatry to come up with a definition of disorders which would clearly demarcate the realms of their work. Previously in the US, psychiatrists had subscribed to biopsychosocial models of psychiatric illness but with a division between more academic biomedical practitioners, and those who practised in the psychodynamic tradition. In DSM III the academic biomedical psychiatrists won. The new classifications were designed to be ‘atheoretical’ (Cole et al.,

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2008, Parker, 2005)as a way of bridging the divides and to avoid debate over aetiology. For example, one of the disorders subsumed into MDD was ‘depressive neurosis’, a condition in the previous edition “manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession” (APA, 1968). Now all references to the effects of life events were removed. Depression was not defined by its aetiology but solely by the symptoms it presented with. There was an emphasis on the criteria being empirically driven and reproducible. They would serve research purposes, allowing clear inclusion and exclusion criteria into trials, and cohort studies. The validity was less certain. For example, diagnosis of Major Depression, introduced the Feighner criteria (one of Kendell’s 12 sets of criteria then available) which were widely thought to be empirically based. Feighner et al. (1972) presented their suggestions as a “diagnostic classification validated primarily on follow-up and family studies”. In fact the criteria for depression largely came from one case-control study of hospitalised patients with ‘manic-depressive disease’ compared to other hospitalised patients with medical problems (Cassidy et al., 1957). It is clear that these patients may be substantially different to those who present in primary care settings. However, this was the basis for the classification that has held sway until this day. As Cole(2008) states “Our current nosologies remain as ‘working hypotheses’ and have no greater validity than the definitions of depression that existed when Kendell wrote in 1976.”

Defeating Depression
Following the changes to DSM III, which was not used at that time in the UK, there were also changes to the ICD classification of depression in 10th version published in 1992. There was a need to re-educate the public and professionals about the nature of depression and how it was treated. So, in 1992 the Royal College of General Practitioners (RCGP), joined together with the Royal College of Psychiatrists (RCP) to launch a campaign to “Defeat Depression”(Sims, 1993). The campaign set out to increase awareness of depression amongst professionals, and amongst the public(Priest, 1991). A central strategy was the publication of new consensus guidelines on the diagnosis and management of depression in the UK(Paykel and Priest, 1992). The biggest change was the removal of the dichotomy between reactive and endogenous depression, so removing the emphasis on the psychosocial aspects of the diagnosis. “Aetiological distinctions such as reactive and endogenous and whether the depression can be explained by stress are no longer regarded as important in defining the presence of the disorder and need for treatment. What matters is presence of the syndrome.”(Paykel and Priest, 1992) This was important because it affected how both the public and professionals saw the condition. The researchers organised a MORI poll to establish public attitudes to depression before the campaign began(Priest et al., 1996). They found that depression was thought of as a response to life events, such as bereavement, unemployment and relationship breakdown. It was not something that should be taken to the doctor. But if it was diagnosed then 91% thought that counselling was an appropriate treatment, whilst only 16% thought that antidepressants were. More than threequarters thought that anti-depressants were addictive. This reflects what had previously been considered the reactive form of depression, a response to life events. Prior to the consensus

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guidelines, both professionals and the public were in agreement that this was not a condition to be treated with medicines. Why did awareness need to be increased? The perception was that suicide rates showed that there were large numbers of people being untreated for mental health problems, and that the reasons for this were that people were not presenting to their doctors, and when they did doctors did not know how to manage the condition properly (Priest, 1991). There was great hope about what could be achieved because a small research study on a Swedish island had shown that an educational campaign had managed to increase prescribing of antidepressants (Rutz et al., 1990) and decrease suicide rates (Rutz et al., 1989). Studies in the UK failed to show similar success. The Hampshire project was a randomised controlled trial administering an educational package consistent with the new consensus guidelines (Thompson et al., 2000). One of the outcomes was the detection of depression by GPs. This was assessed by administering the Hospital Anxiety and Depression scale (Wilkinson and Barczak, 1988), one of the new instruments for detecting depression which came about following DSM III, to consecutive patients presenting in a general practice. Amongst the control group only 36% of depression cases were detected, but in the intervention group it was only 39%. The education programme seemed not to have worked. All patients were followed up and at six months there was no difference in outcome for patients whether they had been part of the intervention or not, and whether depression had been recognised or not. In an accompanying editorial Kendrick (2000) asked why GPs did not follow the guidelines. He asserts that the problem might be with the guidelines themselves and acknowledges three problems. 1. Depressive symptoms are distributed continuously in the population and might vary day to day. 2. Practitioners doubt that antidepressants will work for those suffering from low mood in response to life’s circumstances. There was only one small trial showing that they were. (Of course after the removal of the categories in DSM III no further studies like this were likely to be carried out). 3. Even if depression was diagnosed patients were unlikely to want to take antidepressants for problems which they considered due to circumstances. The finding that only around 40% of depression found by rating scales is detected by GPs is consistent. In 1989 the General Health Questionnaire was administered to patients in a practice in Bristol(Kessler et al., 1999). Again only 36% of those thought to be depressed on the test instrument were also thought to be depressed by doctors. Patients who were found to ‘normalise’ their symptoms were less likely to be thought depressed and it was suggested that this might be one reason for the under-detection of depression in primary care. Iona Heath (1999)suggested that this was moving to medicalise life’s distresses. Normalising symptoms may be a fine coping strategy, and a way of making sense of suffering in an individual’s life. She also questions whether it would be morally acceptable to push a psychiatric diagnosis onto those who were happy to cope in a different way. This was especially questionable given that those ‘cases’ undetected by doctors tended to have better outcomes after one year that those who were diagnosed and treated (Goldberg et al., 1998).

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The rise in antidepressant prescribing
Given the above reports which seem to show how hard it was to change the way depression was recognised and treated in the UK during the 1990s, it may be surprising that now the concern is overtreatment. In the 20 years since the Defeat Depression campaign there has been a four-fold increase in the prescribing of antidepressants (Middleton and Moncrieff, 2011). There are two main types of antidepressants, the older tricyclic antidepressants and the newer selective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants were dangerous in overdose; a particular risk given the increased risk of suicide in those who are depressed. The SSRIs arrived in the mid-1980s and not only were they much safer in overdose but as Rose states they were the first class of psychiatric drugs purported to act on a single neurotransmitter. Between 1995 and 1995 prescriptions for SSRIs had increased by 135% (Donoghue et al., 1996). Over the next 10 years controversies started to appear. Kirsch has published a series of metaanalyses (Kirsch and Sapirstein, 1998, Kirsch et al., 2002, Kirsch et al., 2008) showing that SSRIs are no more effective that placebo, except in severe depression. Even at that the effect is possibly clinically insignificant(Johnson and Kirsch, 2008). In 2000 concerns started surfacing that this class of drugs ,although safe in overdose, may increase the risk of suicide (BBC, 2000). The license for the use of Seroxat in adolescents was withdrawn for this reason(Kendall and McGoey, 2007). In the USA, the Food and Drugs Administration (FDA) prosecuted the maker of Seroxat, GlaxoSmithKline, for with-holding trial data that raised concerns about the safety profile, and there were concerns raised that the UK agency for dug regulation did not take the same action (McGoey and Jackson, 2009). It was within this climate that the first set of National Institute for Clinical Excellence (NICE) guidelines on the assessment and management of depression were published in late 2004, after being ‘in gestation’ from 2001(Whitty and Gilbody, 2005). Given the lack of study evidence showing the benefits of antidepressants in mild and moderate depression they recommended that cognitivebehavioural therapy (CBT) should be the first line of management. The tables seem to have turned on antidepressants and the diagnosis of depression in primary care. Instead of calls for increased diagnosis and treatment there was concern that the diagnosis of mild depression may lead to long-term incapacity from work (Shiels et al., 2004) although it was also thought that the increasing numbers receiving incapacity benefit may have been a medical solution to the political problem of unemployment (Moncrieff, 1999). We have now established that a possible reason for the rising prescriptions of antidepressants in the UK may have been the Defeat Depression campaign. However, this does not seem to be due to increasing incidence (new cases) of depression. In fact, the number of new prescriptions for antidepressants rose from 1993-1997, and has since been decreasing (Moore et al., 2009). The reason for the increasing numbers of prescriptions is that people are taking antidepressants for longer periods of time, often several years.

Deprivation and depression
But what of the even higher rate of prescribing of these drugs in northern England? There is consistent evidence for a relationship between income, educational attainment, deprivation and risk

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of depression at individual and area levels. As with other discussions of inequalities in health, there is debate on whether the relationship is due to social causation (stress and adverse circumstances cause depression) or social selection (depression leads to loss of income and poverty). In the case of depression, from looking at longtitudinal studies, the relationship seems to be social causation (Dohrenwend et al., 1992, Ritsher et al., 2001). Studies in Europe show that unemployment, or economic inactivity, being in poor material circumstances, and lower levels of education are associated with increased likelihood of being depressed or anxious (Fryers et al., 2005). A cross-sectional study in the UK has shown that those with multiple debts are six times more likely to be depressed after adjusting for income(Jenkins et al., 2008), suggesting that strain from debt may mediate the relationship between income and mental health. In a survey in the UK those in debt were also twice as likely to consider suicide after adjusting for other factors including income (Meltzer et al., 2011). Research by economists (Bridges and Disney, 2010) has suggested that depression is affected by perception of financial situation rather than reality. The interaction between income, debt and health is further studied by Lenton and Mosley(2008). They found that high-interest loans had a negative impact on health independent of the level of debt. They suggest that the worry caused by being heavily-indebted might push people into ill-health and make it harder for them to climb out of the poverty trap. So what can be done about this relationship? One approach suggested had been the use of ‘welfare clinics’ in healthcare settings to increase the uptake of benefits by those who are entitled to them and provide support on managing indebtedness. A systematic review of studies (Adams et al., 2006) found that there was no evidence of improved health outcomes but this was thought to be due to the quality of the studies. A randomised-controlled trial of welfare clinic project in Newcatle upon Tyne (Mackintosh et al., 2006) also had a qualitative (Moffatt et al., 2004) evaluation. They found that although participants reported health benefits in the qualitative study- for example sleeping better, and reduced contact with the primary health care team- there was no change in the health outcomes in the quantitative evaluation. Despite 15 different survey instruments being administered it was thought that they might not have been sensitive to the kinds of benefits which the older participants received. There is uncertainty over the role of antidepressants as described earlier, and in older patients they have been found to be less effective in those with low socio-economic status(Cohen et al., 2009). Despite the complexity that individual socio-economic factors seem to bring to managing depression, none of the guidelines investigate whether or not treatments such as CBT will have more or less impact on those who are chronically living with ‘life’s difficulties’. In fact, mental health is now increasingly reframed as a ‘social problem’. But this is not because of its social causes. Instead it is because it is seen as presenting an economic burden to the state.

Depression as a ‘social problem’
The Increased Access to Pscychological Treatments (IAPT) programme has been described as an “unprecedented” (Clark et al., 2009) large-scale initiative to bring these treatments to large parts of the population in England. It was championed by Baron Richard Layard, an economist, when he presented his paper “Mental Health: Britain’s Biggest Social Problem” to the No. 10 Strategy Unit

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Seminar on mental health(Layard, 2005). In it he made the case that more were out of work on grounds of mental health than because of unemployment, and so it was now Britain’s largest ‘social problem’. He points out that “Until the 1950s there was little that could be done beyond improving the social environment. But today both drugs and modern psychological therapies can make a huge difference to the majority of patients” (p.2). So, although the social environment might be causing the condition, and that condition may be leading to further social problems, the solution is not constructed as a social matter. Instead £750 will buy a course of therapy which should lead to 12 months free of illness, and an extra month in work. This should save the government incapacity benefits and generate and extra £850 in taxes (Layard, 2006). Shaw and Taplin(2007)make several criticisms of Layard’s model. They too see it as providing an individual level solution to a societal problem. It does not address structural inequalities in society, uses therapy as a way to compensate for community breakdown (a factor identified by Layard for the lack of increase in happiness over the years despite increased GDP), and the medicalisation of social problems as individual issues. Aside from these reasons for why Layard’s project might fail, there is also the small matter that the sums might be wrong. McPherson et al.(2009)have reviewed the evidence for the therapies that will be offered and have found the outcome measures in the studies to be changes in symptoms scores. They assert that change in symptoms scores does not necessarily equate to ‘recovery’, and an increased likelihood to return to work. The initial evaluations have also shown uptake to be much less than estimated in the initial calculations(Clark et al., 2009). Both might mean that the economist’s model might not be as sound as originally thought.

Biomedicalization of depression
This essay started with a description of how academic psychiatrists removed the psychodynamic elements from depression diagnosis with the introduction of DSM III. In the UK the GP contract Quality and Outcomes Framework (QOF) states that all patients should have the severity of their depression assessed through the use of a standardised, tick-box instrument such as the Patient Health Questionnaire- 9 (PHQ-9). This has meant a further challenge to attempts to discuss mental health in a holistic way with patients. Although initial research focussed on matters as prosaic as “Can PHQ-9 be carried out over the telephone?”(Pinto Meza et al., 2005) later qualitative research addresses the complexities of its use. Dowrick et al. (2009) interviewed doctors and patients. The found that doctors were much more sceptical about the administration of the questionnaire viewing it as a threat to holism, which was unlikely to be valid, whilst many patients were reassured by the methodical nature. A “fuller” picture was being gained. A focus group study with GPs again found that using the instrument was intrusive in the consultation(Mitchell et al., 2011). It was something to be worked around to try and ensure minimal impact. There were also concerns about treating the patient not the score. These accounts are in contrast to the way that GPs discussed managing depression prior to the mandatory introduction of these tools. In an interview study carried out when one such tool was being developed (Thomas-MacLean and Stoppard, 2004)the researchers found that “what emerges when physicians’ accounts about their diagnostic practices become the focus of inquiry is that

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diagnosis is a more complex undertaking than current medical conceptualizations would imply.”(p285)

Conclusion
This essay was prompted by a press story describing how GPs were perceived not to be responding to depression appropriately. I have attempted to show that over the past 40 years the diagnosis of depression has become increasingly reductive, in its definition and in the way the diagnosis is reached in primary care. The psychosocial aspects of depression have been squeezed out of the definitions of the condition. Many GPs tried to retain an understanding of these factors in consultations but the use of diagnostics screening tools has challenged this aspect of the consultation. The Defeat Depression campaign in the UK called for increased recognition and treatment of depression in the UK. There was the perception that many cases were being missed. However many studies have failed to find that there are other true cases to be found. However the prescribing of antidepressants has increased, mainly because many are taking the relatively safe, although possibly ineffective, SSRI drugs for longer. Instead psychological therapies are being championed. These still focus on an individualised, medical model of depression. Although there are clear links between psychosocial strain and what we call depression, the condition is increasingly been viewed as an economic burden to society in the UK, and globally. Perhaps if the weaknesses of pharmaceutical approaches to depression become more apparent to the wider population, there will be increased discourse on the best way forward. Instead, despite unclear aetiology, with a weak concept of diagnosis, there is currently near-hegemony amongst politicians, professionals, the public (who present to professionals), and the press about what depression is and how it should be treated. The presence of only a very few dissenting voices is quite surprising.

Word count: 3585

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