Is there really an epidemic of depression or is it, as some have suggested, forces of medicalization at work? This article looks at pharma’s direct-to-consumer advertising practices of marketing antidepressants and the health insurance industry’s influence on the perception of depression prevalence.
Surviving America’s Depression Epidemic, “Depression: Epidemic for a Postmodern Age,” “Depression: The Hidden Epidemic.” These kinds of titles lamenting or questioning the popular lay and professional conception of depression as increasingly widespread have become more and more common in recent years. It is true that depression is understood by many as a major public health problem of epidemic proportions. The United States Surgeon General’s 1999 report, “Mental Health: A Report of the Surgeon General,” stresses the widespread nature of mental illness, with one in five Americans affected by mental illness each year. The World Health Organization describes depression as an epidemic that will, within the next 20 years, be second only to cardiovascular disease in terms of disease burden worldwide.1
But what is an epidemic? And for that matter, what exactly do we mean when we say “depression?” The U.S. Centers for Disease Control defines an epidemic as: “the occurrence of disease within a specific geographical area or population that is in excess of what is normally expected.” The term depression is used regularly in our everyday lexicon to refer to a variety of concepts relating to weather patterns to the state of our economy. We also use the word depression to describe a fleeting mood state—the disappointment after failing a test or a feeling resulting from a particularly sad or “depressing” movie. However, increasingly over the last few decades, the general public uses depression as physicians and mental health researchers do—to refer to a mental illness called “major depressive disorder (MDD),” which, as described above, seems to be affecting more and more of us each year.
If depression is an epidemic then, according to the CDC definition, depression is a disease. It also means that depression is occurring “in excess of what is normally expected.” But what is a “normal” amount of depression? Is the number of people found to be depressed in U.S. higher than what should be expected? Are those diagnosed in epidemiologic studies as depressed experiencing disease or just plain old sadness resulting from the normal ups and downs of life?
There is no doubt that depression is a serious, debilitating condition for sufferers, who can be helped immensely by professional interventions, including medication. But it remains the case that there is no definitive test—no blood test or x-ray—to confirm or deny someone has MDD. This uncertainty about cause and the widespread nature of depression “symptoms” makes depression diagnosis malleable and suggestible—offering opportunity to the pharmaceutical industry to expand sales by expanding what is considered treatable “illness.”
Medications work on our biology and therefore pharmaceutical companies depend on biological definition of depression to sell their products. Because of the difficulty in identifying clear cut biological mechanisms for the diagnosis of various mental disorders, the degree to which the mental is medical remains contested.
The medicalization of “sadness,” as it is called by critics of the depression as epidemic perspective, points to direct to consumer (DTC) advertising of antidepressants by pharmaceutical companies as a major vehicle in the expansion of depression diagnoses.2,3 “Medication-alization” seems more like it. In 1997, The Food and Drug Administration approved the use of DTC drug advertisements in broadcast media (TV and radio); before that, advertising was relegated to publications targeted at physicians.4 By 2000, the pharmaceutical industry was spending more than $2 billion on DTC advertisements.
DTC ads for antidepressants typically feature the DSM defined symptoms of major depressive disorder in conjunction with explicit reference to biological etiology, defining depression as a “chemical imbalance” or lack of normal levels of the neurotransmitter serotonin in the brain. While this was once a promising theory, science has not borne out the truth of the “chemical imbalance” theory.5 Today’s science increasingly depicts depression as resulting from a highly complex interaction of human biology, genetics, psychology, and social and physical environments. But even though psychiatry shies away from direct claims about cause, the pharmaceutical industry is sticking with what works—and the result is continued sales. SSRIs have come to be some of the best selling drugs of all time, and the success of these drugs has lead to a proliferation of new antidepressants on the market for depression and a variety of other mental health problems.
Managed care and mental health treatment
Around the time that SSRI antidepressants came on the market in the late 1980’s to early 1990’s, managed care was expanding. Managed care prefers the quickest, least expensive treatment alternatives. In the case of depression treatment that means medication over psychotherapy. The result—patients seeking care for depressive symptoms were more than four times more likely to receive medication for depression in 1997 than in 1987.6
What doctors can diagnose and prescribe as treatment is subject to the approval of a patient’s health insurance companies and what it defines as acceptable diagnosis and treatment. To the degree that patients are unable or unwilling to pay for service out of pocket, they must seek the services covered by their health insurance carrier, all of whom employ at least some managed care practices these days. With recent mental health parity legislation, insurance companies being forced to provide increased psychotherapy benefits, but most still have strict limits on coverage, ironically requiring a mental health problem to be deemed “biologically-based” by the provider to get reimbursed for psychotherapy treatment services.
Protecting the healthy
The number of people experiencing the “symptoms” of Major Depressive Disorder may be plenty. No doubt, the symptoms of depression are common and widespread human experiences. We may have a lot of depression going on, but that there’s “disease” in excess of what’s normally expected in this case is less certain.
Contrary to popular sentiment, while lots of people may be experiencing symptoms of depression, it’s not clear that this is occurring at higher rates than in the past, nor is it the case that everybody who goes to their doctor is clamoring for medication. But with Pharma, physicians and health insurance industries telling us that yes, our experience is very common, but no, it is not normal, and that medication is our best option for feeling better, it’s no wonder that we’ve got a society ripe for viewing depression as an epidemic.
No question society needs to make the protection of the rights and interests of persons with mental illness a priority since they have in the past often been ignored and trampled on. But convincing people who are sad or live in difficult circumstances that the only way they can get better is to take a powerful drug carries its own dangers. Only by critically analyzing the social forces that have created the “epidemic” of depression can we chart effective policies to recues its burdens.
Sara Kuppin, DrPH, is a postodoctoral fellow in Urban Public Health at Hunter College.