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1 in 8 (over 3 million) Australians are on antidepressants - Why is the Lucky Country so miserable?

Updated: Aug 25

By Dr Martin Whitely and Dr Melissa Raven

Enquiries to psychwatchaustralia@gmail.com

According to the OECD, in both 2000 and 2015, Australians were the second largest (per-capita) users of antidepressants of the 30 countries for which data was available. Only tiny Iceland (population 340,000), with its frozen, dark, miserable North Atlantic winters, had a higher per-capita antidepressant prescribing rate in either 2000 or 2015.[1]

As detailed in Table 1 below, Australian per-capita prescribing rates have continued to increase since 2015. In the 2018 financial year, over 3 million Australians were prescribed an antidepressant, mainly SSRIs for depression or anxiety.

Table 1 - Number and % of Australian patients (by age group) prescribed an antidepressant from 2012-13 to 2017-18

Source: Department of Human Services data provided to PsychWatch Australia in April 2019 (see far below for the original DoHS documents)

As shown in Table 1, older people are the most likely to be medicated, with 1 in 4 Australians aged over 78 years prescribed an antidepressant, in 2017-18. Among those aged 65 and over, antidepressants are often "used to treat... anxiety disorders, chronic pain and some types of urinary incontinence".[2] It is therefore impossible to determine what proportion of older Australians are prescribed antidepressants for depression or anxiety, and what proportion take them for other conditions.

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. The first Australian Atlas of Healthcare Variation, published in 2015, suggested that, for children, antidepressants are “primarily prescribed for anxiety, rather than depression”.[3] The Atlas also revealed that there are massive geographical variations in antidepressant prescribing rates.[4]

These stunning statistics invite the obvious question: Why do so many Australians take antidepressants?

The question may be obvious, but the answer is not. 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.[5] 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. We enjoy (or rather can enjoy), abundant sunshine, clean air, sensational beaches and open spaces, great food, longevity, a world-class universal access health-care system, robust democracy, rule of law, political and religious freedom, relative economic equity, and a very high standard of living following 27 years of unbroken economic growth.

Australia's Depression Paradox - We report we are happy. Our cities dominate the world's most liveable cities list. Yet 15%+ of adults take antidepressants and the WHO rates Australians as the world's 2nd most depressed people.

Clearly these positives aren't enough to make all of us 'relaxed and comfortable', and there is no doubt, that for some Australians, depression and/or anxiety can be debilitating. Nonetheless, it is very interesting that when asked Australians think they are relatively happy, while the WHO and our own depression experts insist we are relatively depressed. Perhaps Australia's extraordinarily high and rising rates of antidepressant use, and our WHO silver medal for depression, may have nothing to do with Australians being disproportionately depressed. Rather, it may be our mental health system that is very sick, and hooked on a cycle of over-diagnosis and over-medication.

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The following four factors may have contributed to this 'sickness'.

1. The 'by default' adoption of the flawed American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (current version DSM-5) diagnostic model

Since it was published in 2013, DSM-5 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).

The Australian psychiatric profession has effectively outsourced the development of the working definitions of 'normal' and 'disordered' to the American Psychiatric Association, even though the USA has very poor mental health outcomes.

2. Most antidepressant prescribing in Australia is done by time-poor GPs with limited mental health training and few other options[6]

GPs are being sold to Australian consumers as specialists in life but in reality most are experts in 15 minute consultations with at least one medication as the likely outcome.[7]

Many GPs don't have the time or the skills needed to treat individuals distressed by grief, family breakup, unemployment or any other of life's inevitable trials. Too often their only tools are antidepressants, and if all you have is a hammer, everything looks like a nail.

Furthermore, many patients believe that a consultation does not represent value for both time and money if a drug or other tangible treatment does not result. In the eyes of these patients, a clinician who recommends watchful waiting, or lifestyle changes, and does not produce a diagnosis and treatment, is not doing their job. This reinforces the dominance of the medical model.

3. Increasing demands for government to provide or subsidise mental health interventions

There is a growing expectation that Australian governments, both state and federal, will provide free (or heavily subsidised) access to mental health services to large numbers of Australians.

From a government perspective, pharmaceutical interventions appear to be the cheapest and quickest way to meet this demand.

This can be a false economy. Iatrogenic harm (harm caused by treatment)[8] and the failure to deal with underlying causes of distress can create extra long-term costs to both the patient and the system. However, accounting systems rarely identify the long-term outcomes of treatments, and for cash-strapped governments, the appeal of quick, cheap mental health treatments is irresistible.

4. The uncritical promotion by key elements of the Australian media of claims that mental illness is massively under-diagnosed and under-treated in Australia

It is often asserted that psychiatric disorders like depression are illnesses just like any other such as heart disease, diabetes, asthma and cancer. Depression is even sometimes described as a disease. These descriptions are dangerously misleading. There are fundamental differences in our understandings of physical illness and mental illness. Cancer is diagnosed by observing physical abnormalities of body organs and/or at a cellular level. Diabetes results in observable abnormal fluctuations in blood sugar levels. Despite repeated (broken) promises of imminent scientific breakthroughs, none of the 297 psychiatric disorders outlined in DSM-5, are diagnosed by observing physical abnormalities.

Diagnosing depression involves evaluating if a patient demonstrates normal human behaviours (sadness, lack of motivation etc.) to an extent that is considered abnormal and debilitating for at least two weeks. The line between having depression, and not having depression, is fuzzy. Much fuzzier than the distinction between having cancer, and not having cancer.

Estimating the prevalence of depression in a population, particularly undiagnosed depression, is even more problematic. Usually it involves surveying a representative sample to determine how many people demonstrate sufficient symptoms to qualify for a diagnosis. This is often done without considering an individual's life circumstances, and without any of the empathetic interactions that should be integral to every therapeutic consultation. It results in inflated estimates of the prevalence of mental illness.

Given how broad DSM-IV and DSM-5 diagnostic criteria are, these inflated estimates, including claims that "up to one in four young people in Australia are likely to be suffering from a mental health problem",[9] can sometimes be defended on technical grounds. However, associating serious harms with undiagnosed mental-illness, and implying that these harms are avoidable through diagnosis and treatment, is a massive stretch. Too often, it is simply assumed that the results from treated mental illness are far superior to those for untreated mental illness. Sadly, as will be detailed by PsychWatch Australia in coming blogs*, this is dangerous assumption.

The four factors identified above are likely to be only part of the explanation for Australia's exceptionally high and rising rates of antidepressant use. Many of the same factors that are driving up antidepressant prescribing rates in other developed nations are also at work in Australia. However, other comparable countries appear to be less wedded than Australia to a medicalised approach.

In 2018 the UK Government appointed its first Minister for Loneliness.[10] Most people in the UK aged over 75 live alone and about 200,000 older people in the UK have not had a conversation with a friend or relative in more than a month.[11] However, this epidemic of loneliness is not limited to the elderly, as the highest rate of self-reported loneliness in the UK is among those aged 16 to 24 years.[12] Whether a government can help prevent its citizens being lonely and sad is a valid question, and there are already plans to turn loneliness into a discrete psychiatric disorder treated with drugs, but at least the initiative of appointing a Minister for Loneliness reflects an understanding of one of the social drivers of well-being.

This is not to suggest that improved social relationships are the silver bullet for all, or that there is no role for medications. Some patients who take antidepressants report that they have benefited, while others report that they regret ever having started, and that they are having great difficulty withdrawing. Clearly pills work for some, but not for all, and many people experience harms.*

Given the rapid growth in rates of single person households, high rates of family breakdown, insecurity in the workplace and the ageing of the Australian population, perhaps it is not surprising many Australians are distressed and are looking for help. However, these stresses are not medical or biological in origin. It is time for less reliance on chemical treatments, and more emphasis on human approaches to tackling distress and persistent sadness in our lucky country.

*In coming months, PsychWatch Australia will explore growing concerns about the evidence base used to justify the widespread and growing use of antidepressants by children, adolescents and young adults, with particular emphasis on the relationship between SSRI use and suicide.

References

[1] OECD (2017), "Antidepressant drugs consumption, 2000 and 2015 (or nearest year)", in Pharmaceutical sector, OECD Publishing, Paris. Available at https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017/antidepressant-drugs-consumption-2000-and-2015-or-nearest-year_health_glance-2017-graph181-en#page1 (accessed 15 April 2019)

[2] 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)

[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)

[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] 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)

[6] 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)

[7] "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

[8] Waghorn, Geoff, & Lloyd, Chris. (2005). The employment of people with mental illness. Australian e-Journal for the Advancement of Mental Health, 4(2), p.21 https://research-repository.griffith.edu.au/bitstream/handle/10072/55035/72284_1.pdf (16 April 2019).

[9] Patrick D McGorry, Rosemary Purcell, Ian B Hickie and Anthony F Jorm, (2007) Investing in youth mental health is a best buy. Medical Journal of Australia. Available at https://www.mja.com.au/journal/2007/187/7/investing-youth-mental-health-best-buy (accessed 17 April 2019)

[10] Tara John, How the World's First Loneliness Minister Will Tackle 'the Sad Reality of Modern Life'. Time Magazine, 25 April 2018. Available at http://time.com/5248016/tracey-crouch-uk-loneliness-minister/ (accessed 15 April 2019)

[11] Lee Mannion, Britain appoints minister for loneliness amid growing isolation. Reuters, 17 January 2018. Available at https://www.reuters.com/article/us-britain-politics-health/britain-appoints-minister-for-loneliness-amid-growing-isolation-idUSKBN1F61I6 Reuters (accessed 15 April 2019)

[12] UK Office of National Statistics Website. Loneliness - What characteristics and circumstances are associated with feeling lonely? Which factors independently affect loneliness? Available at https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/lonelinesswhatcharacteristicsandcircumstancesareassociatedwithfeelinglonely/2018-04-10#which-factors-independently-affect-loneliness (accessed 15 April 2019)

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​Jon Jureidini. Concerns after data reveals three million Australians now using antidepressants. Ben Fordham.

Concerns after data reveals three million Australians now using antidepressants

2GB.com

ABC Radio 720 Perth- Breakfast with Nadia Mitsopolous 24 April 2019: Interviews with Dr Martin Whitely from PsychWatch Australia and Dr Harry Nespolon President Royal Australian College of GPs and talback callers (Note this is a recording of the whole program. The interviews begin at 2:44:28 and end at 3:16:00).

https://www.abc.net.au/radio/perth/programs/breakfast/breakfast/11027626

ABC Radio Adelaide- Breakfast 24 April 2019: Interview with Dr Martin Whitely (Note this is a recording of the whole program. The interviews begin at 1:18:55 and end at 1:28:30).

https://www.abc.net.au/radio/adelaide/programs/breakfast/breakfast/11027596

Video: Three million reliant on antidepressants - Sydney Morning Herald

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Questions have been raised over GP's methods after data reveals one in eight people are dependant on antidepressants.

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One-in-8 Aussies on anti-depressants - 6PR

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​New research suggests one-in-eight Australians are using antidepressants, including children. Dr Martin Whitely from PsychWatch Australia told Mornings with ...

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​According to a report published on PsychWatch Australia, in the 2018 financial year, more than three million Australians were prescribed anti-depressants.

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Fears over 'frightening' rise of antidepressants | Chronicle

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Fears over 'frightening' rise of antidepressants | Queensland Times

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Mental health researcher and former MP Dr Martin Whitely, who exposed how ... pathologises the normal human experience of trial and error," Dr Whitely said.

Fears over 'frightening' rise of antidepressants | Queensland Times

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​[may be explained by] our mental health system that is very sick, and hooked on a cycle of over-diagnosis and over-medication," PsychWatch Australia said.

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阿德萊德大學精神病學家喬恩·尤雷迪尼(Jon Jureidini)教授認為,抗抑鬱藥正在被過度使用,而且我們正在“治療失望”。“我不想輕視人們的痛苦,但在我們考慮給人們 ...

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精神健康研究员、前联邦议员Martin Whitely最近在新博客上谈到这个问题时说:“我们的精神健康系统是非常病态的,陷入了一个过度诊断和过度服用药物的循环。”.

澳抗抑郁药使用激增过度诊断治疗引担忧_ 澳洲新快网

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PsychWatch机构的支持者、心理健康研究员、前议员怀特利(Martin Whitely)博士透露了班上最小的孩子是如何最有可能被诊断为注意缺陷多动障碍(Attention ...

澳華網- 過度診斷+過度治療數據顯示1/8澳人“被抑鬱”

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心理健康研究人員和前議員馬丁·懷特利博士(Martin Whitely)支持澳洲精神觀察組織PsychWatch的研究,懷特利博士曾揭示了在一個班上,往往年齡最小孩子最有可能 ...

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在过去10年里,因焦虑或抑郁而服用药物的儿童数量增加了两倍,专业人士称这是一场过度诊断危机。 根据澳洲健康监察机构Psych Watch Australia的数据,2018年, ...

澳抗抑郁药使用激增过度诊断治疗引担忧_ 澳洲新快网

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新的心理健康政策监督机构PsychWatch Australia对这些数据进行了强调,质疑医学界 ... PsychWatch机构的支持者、心理健康研究员、前议员怀特利(Martin Whitely) ...

澳抗抑郁药使用激增过度诊断治疗引担忧_ 澳洲新快网

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新的心理健康政策监督机构PsychWatch Australia对这些数据进行了强调,质疑医学界 ... PsychWatch机构的支持者、心理健康研究员、前议员怀特利(Martin Whitely) ...

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Copy of Department of Human Services documents provided to PsychWatch Australia in April 2019 used to prepare Table 1

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