I am troubled by a recurrent practice in the popular literature on the theme of happiness and the economics of happiness. It’s an intellectual sloppiness that I try to guard against but it happens from time to time. The practice is this. There are many articles that comment on happiness by dragging in statistics about anxiety and depression to bolster the perception/argument that unhappiness is endemic. One proof that is frequently aired is the sheer volume of prescriptions for anti-depressants and anti-anxiety medications that is dispensed in the UK, US, name the country under discussion.
Horwitz and Wakefield have offered an excellent overview of what my wife would refer to as the semantic shift of the word depression and what used to be understood by it. Apparently, 300 years ago silly used to mean innocent or blessed rather than its current connotations. In a much faster variation of this process, depression seems to have shifted from a medically defined term to one that is readily used (almost as a metaphor in its own right) to describe any negative emotional state: no matter how appropriate that reaction might be under the circumstances.
It is not unusual to come across reports that claim more than half of the population will develop a mental disorder at some time over the course of life. This immediately raises the issue of what constitutes mental health and mental illness. Although there are internationally standardised criteria for the latter, their application varies enormously. And even psychiatrists can not provide a united front as to where the boundary lies.
To characterise the debate rather crudely, there are doctors who argue that it is timely that we should redefine mental illness broadly enough to incorporate milder conditions that would otherwise be labelled as unhappiness. In this scenario, these milder conditions are seen as prodromes that are pointers to the possible development of more severe problems at a later date. In the same way that raised blood pressure is a prodrome for a variety of cardio-vascular disorders (this is not the place to get into the debate about the on-going redefinition of what is raised blood pressure and the different classifications for it).
Similarly, other experts argue passionately that current definitions should be applied more rigorously so that (inevitably) limited resources are directed to those with the greatest need. There are also some mis-givings as to the social implications of supporting a viewpoint that claims our current social system is so hostile to its citizens that large numbers of the population have mental disorders.
There are also serious questions to be answered about the wisdom of the practice of prescribing an anti-depressant for someone who does not meet the diagnostic criteria for depression. Yet it seems that many GPs find it difficult to refuse a patient’s request for anti-depressants when the GPs do not have ready access to other services or strategies that they might consider more appropriate. Anti-depressants are not mood-brighteners, they are intended to treat depression.
Faced with the lack of local resources, some GPs come up with their own solutions to avoid the requested prescription. One such case is outlined by the excellent Dr. Crippen but I feel that his solution would not be scalable to address the needs of the many patients who present him with dilemmas at (what seems to the layperson) an extraordinary rate. Aside from the dilemmas and ethical quandries that confront GPs in their everyday practice, Dr. Crippen's blog is fascinating reading for many reasons: it is a remarkable insight into the workings of the NHS at the front-line and the actual (rather than spin-doctored) impact of the deluge of reforms.
This already feels like a long post and I haven’t completed my introduction to the topic. Far less have I detailed why I feel that it is inappropriate to use rates of drugs’ prescription to support the theory that unhappiness is widespread, and drugs are one of the major strategies for countering what Lane characterises as an epidemic in The Loss of Happiness.
I would like to have a position of unassailable certainty on the matter of whether unhappiness is a risk factor for more serious disorders and should be addressed agressively, or whether unhappiness is part of the rhythm of life. I’ve previously commented that
Happiness teacher and writer Robert Holden says that a lot of his work consists of showing people that they are already happy.
I would like certainty not least because it would make my work easier to discuss. It may be intellectually honest to admit that you are caught between “on the one hand, this, but on the other hand...” but it doesn’t sound authoritative in any discussion. This is usually where I throw up my hands and declare that this must be yet another instance of the wicked problems that I have referred to in posts about Making Harlow Happy and A Quiet Crisis of Unhappiness.
So, I offer this partial summary of some of the issues that are troubling me. Lane (amongst others) refers to an epidemic of depression. However, it is plausible that this is not an interpretation that can rely safely or solely upon data about the number of prescriptions that are issued or filled for anti-depressants. Some of the issues arising are:
- the clinical diagnostic criteria are not rigorously applied when the decision is taken to prescribe anti-depressants (professional differences of opinion as to where the boundaries lie)
- there has been a marked cultural shift in the common understanding of, and expectations about, the range of normal function
- there is pressure from patients who specifically request psychotropic medication (influenced by items in various media and recommendations from friends and family)
- the pharmaceutical industry has a steady income stream if it becomes socially acceptable to medicate your mood: as with social anxiety disorder, it can even be prepared to create and publicise a disorder that has never previously existed because there is a pharmaceutical remedy
- GPs prescribe anti-depressants because mental health services are not available as a viable alternative
In contrast to the above, there are many fine mental health specialists who claim that there are many people who would benefit from diagnosis or medication: their disorders are unrecognised because they manifest as workaholism or other socially acceptable addictions. Several experts claim that depression is under-reported in men with tragic consequences:
“Men are dropping like flies,” said Dr. William Pollack, a psychologist who directs the Center for Men at McLean Hospital, the Harvard-affiliated psychiatric hospital in Belmont, Mass. “An article in the American Journal of Psychiatry talked about how men are four to six times more likely to commit suicide, and asked why this was happening, if the men weren’t depressed. If we’ve got psychiatrists still asking that question, we’re in trouble. What we need to ask is, ‘What is it about men's depression we're not seeing?’”Dr. Pollack argues that the criteria used to diagnose depression are too “feminized”; as a result, doctors fail to detect the illness in the 60 to 70 percent of depressed men, who, he says, are without classic symptoms. Nor do men tend to recognize depression in themselves. “Men not only don’t get treatment, they try to convince themselves they don't have an illness,” he said. From: Depression Comes Out of Hiding, New York Times
Cutler and McClellan have written a fascinating paper, Is technological change in medicine worth it? They look at whether technological change in five conditions has yielded benefits that exceed the costs. For depression they report that the “diagnosis and treatment for depression doubled over the 1990s”. They argue that an analysis of the data reveals a substantial improvement of quality-of-life from the reduction in symptoms with reported estimates “ranging from 0.1 to as much as 0.6, on a scale where 1 is moving from death to perfect health”. Beyond that, they estimate the equivalent economic value of that reduction is “six times greater than the cost of treament”. They say that this figure does not include productivity gains from the person being able to work. Cutler and McClellan conclude that “increasing rates of treatment among depressed patients is almost certainly well worth the cost”.
The above study was performed on a data set that will include people whom some would argue were miserable rather than clinically depressed. And yet, it still reported economic benefits. I have a hazy memory of other papers that have argued that it is almost impossible to quantify the the true cost of psychosocial distress because of the impact that it has on performance in the workplace or education, and because of the social difficulties that it causes when people can not make the friends and families that are such a protective mechanism in withstanding the vicissitudes of life and even have a measurable effect on our health and longevity.
I will write more about this later. I can say that, notwithstanding the above, I do believe that (in the absence of significant levels of depression or other severe mental disorders) we can improve our level of personal happiness without drugs. Although drugs do seem to be an important part of an appropriate strategy for some people and can be literally life-savers (depression has both a high mortality rate and high co-morbidity rate). I am definitely closing before my language becomes any more tentative or stilted.
Copyright 2006, Tony Plant Happystance Project
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