六九色堂

By

Noel O'Hare

Just because your life's a mess and you're not happy doesn't mean that you need medication.

Instead of catching my usual bus to Misery Place, I'm sometimes tempted to hop on the one to Happy Valley. Though in reality Happy Valley is not a particularly desirable Wellington suburb, with convoys of rubbish trucks trundling through it on the way to the tip, the name conjures up a magical place of great contentment. It's a place where kids do their homework each night without haranguing, where your Lotto ticket always pays out and where you can eat and drink any damn thing you like without worrying about your waistline or your health. Happy Valley may be a fantasy, but Misery Place is a reality for many New Zealanders. The use of anti-depressants has doubled here since 1993, and the prescribing of anti-depressants to under 18s has increased by 60 percent in the past four years.

Why such a huge increase in depression in what every nightly news bulletin confirms is one of the most peaceful and prosperous corners of the world? Professor Roger Mulder of the Christchurch School of Medicine and Health Sciences believes that anti-depressants may be over-prescribed for what is mild and transitory depression or simply unhappiness. Just because your life's a mess and you're not happy doesn't mean that you need medication. "There's really no good evidence that a medical approach to mild depression is successful," says Mulder. "Has unhappiness become conceptualised as depression? One of the problems with that is that people become sort of victims rather than controllers of their own destinies. And resources may go to them rather than to the severely depressed, because they tend to be more articulate and better at requesting resources."

Redefining unhappiness as mild depression puts it in the medical marketplace. It means, says Mulder, that "drug companies can market their drugs to a much broader ranger of symptoms and say they're useful … [they] have worked out that rather than competing with each other, you expand your market". The boundary between illness and what used to be called life is becoming increasingly blurred. In the UK, for example, men are now being treated for postnatal depression (PND). According to Mary Alabaster, the manager of maternal mental health services in Essex, PND in men is "triggered by a wide variety of causes" and that "it really has to be taken seriously". The advocacy group Men's Health Forum claims that 10 percent of men suffer from PND.

Mulder is at pains to point out that anti-depressants are very effective for those who suffer from severe or chronic depression. But not much more than placebos, it seems. In 2002, psychologist Irving Kirsch analysed previously secret trials of the six most widely prescribed anti-depressants - generically known as Selective Serotonin Re-uptake Inhibitors (SSRIs) - obtained under the US Freedom of Information Act. After sifting through the data from studies involving nearly 7000 patients, he concluded there was little difference between a placebo and an anti-depressant: "By far, the greatest part of the change is also observed among patients treated with inert placebo. The active agent enhances this effect, but, to a degree, that may be clinically meaningless."

One of the factors that lends the Kirsch study credibility is that it included unpublished trials. It has been estimated that around 23 percent of anti-depressant drug trials are not published because the results were not what the drug industry-funded researchers hoped to find.

Presenting an incomplete picture of a drug's effects can be potentially dangerous. A recent Lancet study, for example, analysing published and unpublished data on the use of SSRIs by children under 18, found that (with the exception of Prozac) the risks outweighed the benefits. The researchers warned: "Non-publication of trials, for whatever reason, or the omission of important data from published trials can lead to erroneous recommendations for treatment." In March, the US Food and Drug Administration asked the manufacturers of SSRIs (including Prozac) to "include in their labelling a warning statement that recommends close observation of adult and paediatric patients treated with these agents for worsening depression or the emergence of suicidality".

The Medical Association's GP Council has acknowledged that anti-depressants may sometimes be prescribed because psychological help is not available. Evidence suggests that talk therapies, particularly cognitive behaviour therapy, are much more likely to help young people under the age of 18 than drugs. "The dirty little secret of biological psychiatry is that every single drug in the psychopharmacopoeia is palliative," prominent US psychologist Martin Seligman told Edge magazine. "That is, all of them are symptom suppressors, and when you stop taking them, you're back at square one. In general, for depression, for example, seratonin and the earlier tricyclic anti-depressants work about 65 percent of the time. Interestingly, the two major forms of psychotherapy for depression - cognitive therapy and interpersonal therapy - are a tie. They work about 65 percent of the time. The difference is on relapse and recurrence. In interpersonal and cognitive therapy, you actually learn a set of skills that you remember, so three years later, when depression comes back, you can start disputing catastrophic thoughts again. But if you had seratonin or tricyclic anti-depressants, three years later, when it comes back, it comes back in full force."

Seligman, who is president of the American Psychological Association, believes that clinical psychology is half-baked in the sense that it has relieved a lot of suffering, but has done little to help people live happier and more fulfilled lives. About 90 percent of the science of psychology is now based on the disease model, he says.

Some inroads are being made in defining happiness, or eudaemonia, the good life, as Seligman calls it. Researchers, for instance, have found that gratitude - telling someone they made a big difference to your life - makes people lastingly less depressed and happier than a placebo. There is an academic Journal of Happiness Studies in which researchers analyse and compare the strategies of happy and unhappy people in papers such as "The Art of Buying: Coming to Terms with Money and Materialism". Consumers who set out to maximise their purchase by choosing the best possible product often end up less happy than those who just want to find something acceptable. "For example, in advance of purchasing a new car, a maximiser might spend more time talking to dealers, reading statistics and comparing options packages, but he will ultimately be less satisfied with the chosen vehicle than someone who spends less time and effort on the decision."

Despite what the advertisers would have us believe, happiness is not a 106cm plasma-screen TV (if Sony want to try to convince me otherwise, they know where I live). To be truly happy, you have to have a meaningful, fulfilled life, believes Seligman - knowing what your highest strengths are and deploying those in the service of something you believe is larger than you are. It's about meaning, not good and evil. "One of the things people don't like about my theory," says Seligman, "is that suicide bombers and the firemen who saved lives and lost their lives had meaningful lives."

Copyright 2004, Used with permission from the New Zealand Listener.