Is Depression at Epidemic Levels?

Mental Health Foundation of New Zealand

Discussion paper January 2012

Introduction

Depression is increasingly being perceived as a global problem of rapidly increasing dimensions,

or as a modern-day ‘epidemic’. This perspective is widely articulated by the World Health
Organization (WHO), and is clearly evident not only in popular media coverage of health issues,
and within depression-related ‘self-help literature and online resources, but also in government-
produced public health material. While the term ‘epidemic’ does not tend to be specifically used in
clinical literature (or by WHO), there is, nonetheless, a dominant view of dramatically increased
depression prevalence within the sphere of psychiatry/psychology.

There is compelling evidence for dramatic rises in prescription rates for antidepressant
medication within the last two decades (as is explored in a separate paper; Mental Health
Foundation, 2012). However, the assumption that increased diagnosis reflects a rising rate of
depression per se deserves scrutiny. Some psychiatric literature has argued that apparent
increases in depression rates are an ‘artefact’ of other factors, including expanding diagnostic
criteria and an associated trend towards medicalising distress. This has led to a significant
tension within psychiatry and related domains over the scale of ‘the depression problem’.

Given this lack of consensus among mental health professionals and researchers, it is important
for us to ask how robust the evidence for the epidemic view is and whether more people really
are more likely to be depressed now than in previous eras. Only then will we know whether we
are responding appropriately to the problem of depression, both in the clinical sphere and more
broadly in society.

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Objectives

This paper explores the evidence for the apparent rise in depression rates by surveying
psychiatric and psychological literature on depression. It then considers some key assumptions
that currently underlie the way depression has come to be talked about and responded to in the
clinical/academic domain and, ultimately, within popular discourse, and examines other factors
that have been identified by critics as fuelling the perception that depression has reached
epidemic proportions. The discussion identifies a number of ongoing ‘in-house’ professional
debates about the nature, cause and appropriate treatment of depression, highlighting what
Summerfield (2006a, p. 161) described as ‘a number of under-examined fault lines running
through the medical literature on depression’.

Evidence for a depression epidemic

There is a growing perception of a global ‘epidemic’ of depression within academic literature and
public health material, which frequently cite WHO’s (2001) projection that depression will have
become the second most disabling disease globally by 2020. This perception is compounded by
the widely held belief that depression is chronically under-diagnosed in the general population,
and therefore generally undertreated. This view is evident in the bulk of contemporary psychiatric
and public health literature, which often references WHO estimates that only 25% or less of those
suffering depression worldwide have access to treatment. As Summerfield (2006a) observed,
depression is consequently widely reported as a ‘largely hidden’ contributor to the global burden
of disease. This view of the scale of unrecognised depression morbidity is also clearly evident
within New Zealand public health material, such as the Ministry of Health’s website on depression
(www.depression.org.nz/). The annual prevalence of major depression in New Zealand is
currently recorded as 5.7% (Oakley Browne, Wells, & Scotts, 2006).

Proponents of this ‘epidemic’ view of depression (e.g. Hickie, 2007) argue that all efforts should
be made to address this level of unmet need (and associated societal and economic burdens) by
targeting this under-diagnosed cohort for diagnosis and treatment. It is considered that improved
overall diagnosis rates would likely result in a reduced suicide rate, increased productivity,
decreased social stigma and discrimination around mental illness, and improved physical health,
as well as a reduction in problems that are often associated with depression, such as drug and
alcohol abuse. It is argued that more harm is caused by failing to diagnose serious depression
(which may lead to suicide) than by ‘over-diagnosis’ and its consequences, such as the use of
antidepressant drugs by those who may not need them; indeed, Hickie (2007) argued that there
is little evidence to demonstrate that this is a comparable harm. There is however inconclusive
evidence about the extent to which depression is a causal factor of suicide Nock et.al(2009).

The perception of a dramatically increasing prevalence of depression rests mainly on

epidemiological data, which are primarily obtained through population surveys such as WHO’s
Composite International Diagnostic Interview (CIDI) survey (Jorm, 2006). In this survey, data from

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national surveys (i.e. individual country surveys) were extrapolated to produce more generalised
estimates of prevalence, including inter-country and global estimates. National surveys are seen
as useful in offering clear figures on numbers of people with particular disorders (i.e. prevalence
rates), groups most at risk of certain disorders, impacts on society, rates of service use, and an
estimation of unmet need. They are also seen as useful in allowing rates of mental illness in the
general population to be compared with numbers presenting in the clinical setting. Such studies
are widely cited as reporting a marked increase in major depression (as defined by the Diagnostic
and Statistical Manual of Mental Disorders (DSM)) during the second half of the 20th Century
(Mulder, 2008). Hawthorne, Goldney and Taylor (2008) noted that cross-national birth cohort
studies that were conducted in the 1980s and 1990s (e.g. Klerman & Weissman, 1989;
Weissman et.al, 1996; Murray & Lopez, 1996) continue to inform future predictions around the
global burden of disease, and the framing of depression as an emerging public health crisis in
both developed and developing countries (Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray,
2004).

Such data have a major influence on mental health policy in New Zealand, as internationally. For
example, a study by Klerman & Weissman (1989) and the 1992 Cross-National Collaborative
Group study (Weissman et al., 1992) are widely cited in literature on depression in support of the
‘epidemic’ hypothesis. In the Australasian context, prevalence data produced by national surveys
such as the Australian National Mental Health Survey and New Zealand’s Te Rau Hinengaro
(2006) are also cited as evidence of an increasing prevalence of depression in the general
population and claims of growing depression rates, with Joyce, Oakley-Browne, Wells, Bushnell
and Hornblow (1990, p. 83) noting that ‘New Zealand, like other countries, may be entering an
age of melancholy’.

It is important to note, however, that for at least two decades, the epidemic view of depression
has been the subject of debate within the clinical domain, chiefly by academics/clinicians who
propose alternative explanations for the apparent world-wide rise in depression. The following
section explores each of the counter-arguments to the epidemic hypothesis, which question the
extent to which depression can and should be appropriately classified as a distinct ‘disease’.

Other reasons for an apparent increase in depression rates

Changes to the definition and diagnosis of depression

The DSM manual, published by the American Psychological Association (APA), classifies specific
mental disorders according to patterns of symptoms. It is used by clinicians for diagnosing mental
disorders, and also by researchers, pharmaceutical companies, policy makers, and health
insurers. DSM is the most widely used diagnostic manual in the United States and many other
countries (another widely recognised diagnostic guide, the International Classification of
Diseases, criteria for mental and behavioural disorders (ICD-10) is produced by WHO).

The diagnostic category ‘major depression’ was first introduced by DSM in 1980 (DSM III) and
has only come into frequent use since this time (McPherson & Armstrong, 2006). As Horwitz
(2010) noted, prior to the 1970s mental health treatment and research was underpinned by a

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considerably broader concept of mental health problems, which saw mental distress as
substantially grounded in stress and anxiety. This perspective allowed depression to be
considered as a reaction, rather than exclusively as an endogenous disorder.

The 1980 revision of DSM saw a shift from the recognition of generalised conditions to the
classification of specific disease categories, based on the assumption that conditions such as
depression ought to be recognised as distinct, clearly identifiable syndromes, with a basis ‘in the
brain’ (Mulder, 2008). This attempt to impose diagnostic uniformity and to produce a standardised
diagnostic language has often been attributed to psychiatry’s attempts in previous decades to
‘professionalise’ itself through closer alignment with the discipline of science (Greenberg, 2010).
As Horwitz (2010) noted, this resulted in a radical shift away from the psychoanalytic model of
psychiatry, which had previously been the dominant therapeutic approach.

Previous editions of DSM had reflected a view of mental health as a continuum of behaviour,
without clear distinctions between ‘normal’ and ‘abnormal’. However, the 1980 revisions
foregrounded a medical model of mental illness, a shift which many have subsequently held
responsible for an overly-medicalised response to depression, including the ascendance of
pharmaceutical therapies over previously popular psychotherapeutic approaches within
psychiatry. As Horwitz (2010, p. 133) noted, this shift has had far-reaching and profound
implications for the subsequent response to mental illness:

The movement from generalized conditions grounded in anxiety to specific disease

categories dominated by depression has had major consequences for mental health policy.
Because the targets of mental health treatment came to be viewed as specific diseases, the
use of drug treatments, particularly antidepressants, soared. Responses to common mental
health problems became equated with the prescription of medication at the expense of
alternative psychotherapeutic approaches. At the same time, the use of psychological and
social options for common mental health problems has substantially declined, despite
evidence that they are at least as effective treatments as pharmaceutical (and that the
combination of various therapies can be the most successful as all.

Consequently, much of the ‘medicalisation’ critique of current psychiatry (see below) relates to the
development and current use of DSM.

A key criticism of DSM concerns the reliability and validity of diagnoses produced by the use of
standardised diagnostic criteria. For example, McPherson & Armstrong (2006), Mulder (2008) and
others have questioned the validity and reliability of attempts to define and classify depression,
which, unlike the majority of other clinically-recognised diseases such as diabetes, lacks an
agreed biological cause. As Mulder (2008, p. 240) noted, studies of patients with major
depression have ‘failed to demonstrate any coherent pattern of neurobiological changes’.

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Those who question current diagnostic protocols argue that attempts to definitively categorise
depression are based on a fallacious assumption that depression is a ‘distinct and recognizable
syndrome’ (Mulder, 2008, p. 239). For example, as Parker (2005, p. 469) noted:

While major depression is commonly viewed as a ‘valid’ psychiatric diagnosis, it fails to meet
any of the orthodox criteria for validity. It does not have a clear-cut clinical picture (a
depressed mood state being the only obligatory component), its boundaries are unclear
(because they reflect dimensional rather than natural cleavages), its natural and treatment
history are difficult to predict at an individual level, while cause and response to treatment are
again more related to factors in the individual sufferer than being integral to the disorder

Mulder (2008) argued that reliance on descriptive, symptom-based diagnostic criteria is

problematic as it does not take into account the significance of context in contributing to individual
mental distress (for example, the presence of environmental stressors), and the relevance of this
knowledge for determining an appropriate response. As he noted, the symptoms of depression
listed in DSM are in fact commonly experienced in the community, not only by those who are
diagnosably ill, but also by those who are experiencing levels of distress commensurate with their
circumstances. Thus, as he suggests, ‘the evidence does not support a distinct homogenous
illness called DSM depression’ (Mulder, 2008, p. 241), and therefore the usefulness of a
standardised treatment response is questionable, as inappropriate diagnosis may be given (or
appropriate diagnoses missed).

Critics of DSM also argue that current diagnostic categories set the threshold of diagnosis too
low. The reliance on a symptom-counting approach to diagnosis (what Mulder (2008, p. 244)
referred to as a ‘checklist mentality’) is seen as creating arbitrary distinctions between categories
of disorder, failing to take into consideration degrees of distress and impairment. Thus, according
to this view, apparent increases in specific disorders such as major depression may in fact simply
be an artefact of the expansion of diagnostic criteria (Mulder, 2008).

Mulder (2008) argued that to avoid the inappropriate classification of normal distress as mental
illness, DSM needs to be refined, with useful changes including a move from the use of simple
yes/no questions towards a more in-depth, unstructured interview format. As he noted, ‘The
ultimate goal is to more clearly separate the depressed patient from the distressed one’ (Mulder,
2008, p. 245), and this may be better achieved through placing greater emphasis on subjective
symptoms (i.e. an individual’s own qualitative assessment of their own mood and degree of
distress).

Over-diagnosis, or the medicalisation of distress

A number of scholars and clinicians within psychiatry have argued that while the production of a
symptom-based definition of depression has produced some benefits (including improved
diagnosis and treatment for those with serious illness, decreased social stigma of mental illness
and increased research interest), the expansion of diagnostic criteria for mental illness has
nonetheless produced a number of costs by ‘medicalising’ understandable experiences of

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sadness (Parker, 2005, 2007; Mulder, 2008; Greenberg, 2010; Horwitz, 2010). Ongoing changes
to the DSM criteria (including the controversial removal of the notion of ‘reactive depression’) are
seen by critics as having contributed to an unhelpful decontextualisation of personal experience
in psychiatry; that is, a model of diagnosis that does not sufficiently allow for the recognition of
depressed mood as a reaction to personal circumstances (and life history), rather than
necessarily as a biologically-based illness. As Parker (2007, p. 335) noted, many of the clusters
of symptoms viewed as diagnostic of depression are experienced by most people on and off
during their lives, and so ‘It is normal to feel depressed’. Similarly, Chodoff (2002, p. 628) noted
that ‘… no subjective checklist of a patient’s history and complaints can infallibly separate clinical
syndromes that qualify as disorders from various kinds of human discomfort of a lesser intensity’.

Although clinical literature does indicate considerable benefit in diagnosis and treatment for many
people with severe depression, the evidence of ‘best practice’ for responding to less severe types
of depression (i.e. mild to moderate) is less robust and tends to be rather contradictory. As
Chodoff (2002, p. 627) suggested, ‘Severe clear-cut depression, especially if combined with
manic phases, is an unequivocal disorder that conforms satisfactorily to the medical model.
However, less severe episodes of depressive affect cannot always be accurately distinguished
from ordinary human unhappiness or “the blues”, states of mind that do not justify a diagnostic
label’.

Consequently, there is a key concern that there is now a culture of over-diagnosis, with current
diagnostic criteria for depression placing the threshold for clinical depression too low. As a result,
it is suggested that a large number of people experiencing normal emotional responses to life’s
problems are categorised as clinically ill, and may subsequently receive treatment of no personal
value and potential harm, with little consideration for the extent to which depressed mood reflects
a reaction to difficult circumstances. In this view, the supposed depression epidemic is not so
much the discovery of a long-recognised disease but rather a ‘reconstitution of a broad swath of
human experience as illness’ (Greenberg, 2010, p. 18). As Parker (2007) suggested, the inherent
potential for over-diagnosis has been compounded by growing clinical interest in identifying
‘subclinical’ mood disorders as an area of unmet need.

A related concern is that excessive diagnosis rates have resulted in the over-prescription of
antidepressant medication, with any manifestation of depressed mood now being widely viewed
as a mandate for clinical treatment (chiefly drug prescriptions), even though other valid, evidence-
based approaches (including psychotherapy and improved social support) may be more helpful
and appropriate in many instances (see below).

Further concerns are that receipt of a clinical diagnosis of illness may be a disincentive for those
with milder forms of depression to seek self-directed solutions to their problems. As Moncrieff
(2002, p. 191) argued, the promotion of a drug-based solution to depression has a powerful
psychological effect:

The prescription of medication for depression conveys the powerful message that we are
passive victims of our biology. The consequences for the individual may include failure to
develop intrinsic coping strategies, leading to psychological dependence on drug treatment

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 and increased susceptibility to recurrence. At the social level the effects may contribute to the
tendency towards increasing perception of ill health and recourse to medical intervention.

Conversely, it is argued that excessive diagnosis of depression individualises social problems and
distracts policy-makers from addressing the broader social determinants of poor mental health
(Greenberg, 2010). As Summerfield (2008, p. 993) argued, ‘The danger of the medicalisation of
everyday life is that it deflects attention from what millions of people worldwide might cite as the
basis of their distress – for example, poverty and lack of rights’.

Thus, according to the ‘medicalisation’ criticism of the depression epidemic, the apparent rise in
depression ought to be recognised as an ‘artefact’ of the expansion of diagnostic criteria in recent
years; that is, as primarily due to excessive diagnosis (Mulder, 2008).

An epidemic of antidepressant prescribing

Rates of antidepressant prescription often appear to be viewed as a proxy measure for

depression rates. There is widespread recognition within psychiatry and related disciplines that
rates of antidepressant prescription (in particular of selective serotonin re-uptake inhibitors
(SSRIs)) have expanded rapidly since the 1990s. This trend is also reflected in the New Zealand
context, where such prescriptions are reported to have doubled from 1.1 million in 1997 to 2.1
million in 2005 (Ministry of Health, 2007). However, whether this increase in prescribing actually
reflects an increased rate of depression is worthy of discussion.

It is notable that the concern raised in clinical literature about the unmet need for treatment for
depression widely assumes that a medical response (chiefly, the use of antidepressant therapy
as a standard first-line treatment) is appropriate. For example, Virani (2004, p. 2) noted that ‘Most
individuals are either not receiving treatment or receiving treatment that is inappropriate (e.g.
wrong drug) or not properly optimized (e.g. dose too low)’. As Mulder (2008, p. 239) noted, the
emphasis on drug therapy reflects a broader imperative to standardise treatment models, and
‘There appears to be a belief that guideline-concordant evidence-based care will reduce the
disability for all with major depression if only clinicians could be taught to deliver it effectively’.

Critics of this emphasis on pharmaceutical solutions argue that it is current rates of

antidepressant prescription, rather than depression per se, which should urgently be recognised
as having reached epidemic proportions. For example, Summerfield (2006a, p. 161) stated that:

There is, in fact, no sound evidence for an epidemic of depression (as psychiatric disorder) in
the UK. On the other hand, the case for an epidemic of antidepressant prescribing is now
cast iron. In Britain prescriptions rose from 9 million to 21 million during the 1990s, and in the
USA have doubled every 5 years – mirroring the production and marketing of SSRI (selective
serotonin reuptake inhibitors) antidepressants.

The evidence base for the therapeutic value of antidepressants for non-major forms of depression
is clinically recognised to be contradictory, with a number of recent large-scale studies
demonstrating little or no benefit of antidepressants over placebos (e.g. Kirsch et al. 2008;

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Fournier et al. 2010). Increased clinical reliance on a pharmaceutical solution to depression is
seen as having built a public perception of drugs as the ‘gold standard’ treatment for depression,
fuelling popular demand for, and acceptance of, antidepressants. As Summerfield (2006a, p. 162)
noted, ‘The surge in anti-depressant prescribing is as much a cultural trend as a medical one,
reflecting the rise of a medicalisation and professionalization of everyday life and its problems
across Western societies’.

It should also be noted that anxiety is often categorised as ‘co-morbid’ with depression, rather
than viewed as a stand-alone disorder, and so many people are prescribed antidepressants for
anxiety rather than for depression per se. The extent to which this contributes to overall increased
use of antidepressants probably deserves more scrutiny.

This concern extends to the criticism of pharmaceutical involvement in defining and categorising
mental illness; in particular, the extent to which drug companies, clinicians and researchers may
have a vested interest in the ongoing expansion of diagnostic criteria/medicalisation of normal
sadness and distress. For example, Mulder (2008) and others have argued that pharmaceutical
companies may have deliberately fuelled the perception of a depression ‘epidemic’ by overstating
rates of depression in industry-sponsored research. Moynihan, Heath and Henry (2002, p. 886)
noted that corporate involvement in ‘disease mongering’ (and the impact this has on medical
practitioners, public consciousness, and health policy and funding) is an issue that as yet has
attracted ‘limited critical scrutiny’. In fact, the ethics of pharmaceutical company sponsorship of
depression research (and selective reporting of study results) has been an issue of long-running
concern within psychiatry (e.g. Moncrieff & Thomas, 2002; Moncrieff, 2007). However, it seems
reasonable to suggest that the public are largely unaware of this debate, or the extent to which
current treatments have been shaped by corporate interests. As Mulder (2008) and McHenry
(2006) have argued, this raises a variety of unaddressed ethical questions about the dominance
and assumed benefits of the current treatment protocols.

Greenberg (2010) surveyed the historic role of pharmaceutical industry involvement in shaping
the current populate ‘climate of opinion’ that drug therapy constitutes the most appropriate
therapeutic response to depression. He argued that depression as we now understand it is a
modern concept that has essentially been ‘manufactured’, to some extent by drug company
interests. In his view, a key contribution of the pharmaceutical industry to the ‘epidemic’ view has
been in the ‘invention of a brain disease out of our daily troubles and aspirations’, in particular
through promoting the idea of depression as a disease with a biological basis (Greenberg, 2010,
p. 321). He and others argue that pharmaceutical companies have historically exerted
considerable influence in the development of diagnostic criteria, for example through the financial
sponsorship and research support of those involved in the authorship of DSM. The
pharmaceutical industry is also seen as having played an active role in shaping the current bio-
medical model of psychiatry, in large part by promoting the view that depression is caused by a
chemical imbalance, a view that necessarily implies a pharmaceutical (i.e. chemical) solution. As
Mulder (2008) argued, this view of depression continues to significantly influence the current
shape of health service provision for mental illness, including the provision of funding for
treatment and research.

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Critics of the dominance of drug therapy in depression treatment argue that there is a
considerable gap between what the public believe and the evidence-base utilised by clinicians
themselves. For example, few clinicians would now subscribe to the theory that depression is
simply caused by a lack of serotonin, a theory widely promoted in the 1990s; within psychiatry,
the cause of depression is now theorised as considerably more complex. However, the view that
depression is essentially a chemical imbalance in the brain continues to be one that appears to
be widely accepted by the public, and continues to be reiterated in public health material. As
Fournier et al. (2010, p. 52) recently noted, there is currently a lack of awareness about the
limitations of the existing evidence base that underpins current antidepressant use:

Prescribers, policy makers, and consumers may not be aware that the efficacy of medications
largely has been established on the basis of studies that have included only those individuals
with more severe forms of depression. This important feature of the evidence base is not
reflected in the implicit messages presented in the marketing of these medications to
clinicians and the public.

A problematic consequence of this emphasis on pharmaceutical solutions to depression appears

to be that there has been little serious investment made in researching effective non-drug
treatments, resulting in an unbalanced evidence-base. As Mulder (2008, p. 245) noted, non drug
approaches are often ‘implicitly criticised as being under treatment’.

There is a substantial and growing evidence base for the efficacy of non-medical approaches to
managing mild to moderate depression (Jorm, Christensen, Griffiths, & Rodgers, 2002). For
example, a number of studies have found that talking therapies are an effective treatment for
depression (e.g. Antonuccio, Danton, & DeNelsky, 1995; Hollon et al., 2005). There is also a solid
evidence base for the therapeutic efficacy of physical exercise in the management of mild to
moderate depression (Halliwell, 2005). However, such research does not appear to be widely
promoted (or funded) within the dominant biomedical model of psychiatry, and is consequently yet
to attract widespread public support.

For further discussion around the increased use of antidepressants and prescription rates, see
‘Increasing antidepressant rates in New Zealand’ (Mental Health Foundation, 2012).

Measurement challenges

In addition to debates around how depression is defined and diagnosed, the question of how to
appropriately measure rates of depression is a further issue of contention within psychiatry.

As noted earlier in the paper, prevalence data obtained from population surveys are currently
most often used to support the epidemic view of depression. However, some scholars and
clinicians question the suitability of quantitative/epidemiological measures of prevalence for
extrapolating depression rates in the general population. Indeed, population screening is
recognised within psychiatry as a dubious measure and has been dismissed as ‘inherently
ludicrous’ by prominent psychiatrists such as Summerfield (2008), who asked ‘how many British

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Journal of Psychiatry readers believe that 16% of UK citizens have a mental disorder requiring
treatment?’ (2008, p. 329).

Jorm (2006), Summerfield (2006a, 2008) and Hawthorne et al. (2008) have similarly questioned
the use of standardised measuring tools such as surveys for producing prevalence figures.
Hawthorne et al. (2008) argued that this form of data does not present a consistent, reliable
picture of depression rates, noting that while birth cohort studies indicate that depression
prevalence is increasing, this is not reflected in longitudinal studies (Hawthorne et al.’s (2008)
Australian Study did not find evidence for the theory of increasing prevalence within the general
population).

Mulder (2008, p. 238) also criticised continued reliance on this form of data, describing it as ‘the
surveying of symptoms out of context’. In a similar vein, Jorm (2006, p. 833) argued that reliance
on a purely epidemiological approach when attempting to build a picture of the scale of the
depression problem is not ‘scientifically defensible’, noting that this approach has been
responsible for the creation of a number of popular ‘myths’ about the nature and prevalence of
mental illness in society. He argued that the standard approach to producing prevalence rates
(interview surveys such as the CIDI) are ‘arbitrary constructions of the diagnostic criteria and of
the measuring instrument’ (Jorm 2006, p. 831), as this approach is based on several incorrect
assumptions – that mental disorders can be described as categorically distinct, and that
symptoms experienced by individual people can be arbitrarily grouped into specific diagnostic
categories.

A further line of criticism concerns the validity of inter-country comparisons of prevalence rates as
a basis for global measurements and predictions, and for the development of universal treatment
protocols. For example, Summerfield (2006a) argued that there is little evidence that cross-
national comparisons using national prevalence data can be validly used to build a picture of
global depression rates. As he suggested, ‘There is no such thing as depression, if by this we
mean (as the WHO appear to mean) a unitary, universally valid, pathological entity requiring
medical intervention’ Summerfield (2006a, p. 162). Furthermore, Mulder (2008) argued that large
variations in rates between countries (for example, yearly prevalence of major depression is
reported at 0.8% in Nigeria and 9.6% in the United States) suggest that apparent global increases
in mental illness are more likely to be explained by cultural variables than an actual significant
rise in mental illness. However, despite such debates, epidemiological data and cross-national
comparisons continue to be used as the basis for future global projections of depression rates.

Conclusions

There is a need to scrutinise the evidence base for the widespread view of depression as a
contemporary worldwide ‘epidemic’. As Mulder (2008) suggested, the orthodox response to
depression is underpinned by three assumptions: that there is a clearly definable illness called
‘major depression’, that this illness is increasing and that a medical solution is the most
appropriate response. These assumptions need to be revisited and the approaches currently

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taken to address depression at the level of individual treatment and care, as a public health
concern, and at the broader social policy level need to be assessed.

Greenberg (2010, p. 125) argued that depression is an illness whose understanding and
treatment still rests firmly ‘in the hands of the medical elite’, even though it is a disease that
continues to lack a known biomedical cause. Thus, while the public may assume that there is
medical consensus about the ‘facts’ of depression, this is not the case. There is much ongoing
debate within psychiatry and related domains about how depression should be defined.

The existence of professional ‘fault lines’ beneath the orthodox view of depression therefore
deserves recognition, as it raises the possibility that current diagnostic and treatment protocols
may not necessarily provide the best guidance for responding to the problem of depression. As
many critics of the ‘epidemic’ view argue, it is time to revisit the diagnosis and measurement of
depression, and debate the dominance of a medical model solution for depression. This would
require not only serious intellectual and financial investment in therapeutic alternatives to
antidepressants (to produce a more balanced evidence base), but also a political and
professional will to address issues of context and social structure, and their significance for public
mental health policy. As Mulder (2008) argued, whether or not depression is conceptualised as an
epidemic, more attention needs to be given to the reasons for high rates of depression in the
population, rather than exclusively resourcing ‘containment’ strategies such as clinical research,
treatment and anti-stigma campaigns.

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