In lieu of an abstract, here is a brief excerpt of the content:

If you are not already sure that depression is a major global health issue, consider the following statistics. One in six people will experience depression over the course of a lifetime.1 The incidence of depression is estimated to have increased from 50 cases per million people in the 1950s to 100,000 cases per million in the late 1990s.2 In 2004, depression was the third highest contributor to the global burden of disease, at 4.3 percent.3 In the same year, however, depression was the leading cause of disease burden in high- and middle-income countries, at 8.2 percent and 5.1 percent, respectively.4 Greenberg estimates that depression cost the U.S. economy U.S. $83 billion in 2000, of which U.S. $26 billion comprised treatment costs and U.S. $52 billion represented workplace costs, including absenteeism and performance impairment.5 To say these figures are disturbing risks serious understatement. However, statistics, even of this enormity, are still only a dispassionate measure of melancholy’s reach. William Styron, a writer who experienced depression at first hand, gives a more intimate account: [D]epression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this cauldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.6 Styron’s description makes plain why so many with depression are driven to seek relief through the health care system. In my own nation, Australia, about three-quarters of depression sufferers attend their general practitioner7 and nearly 80 percent of those are treated with antidepressant medication (ADM).8,9 In 2004–2005, Australian primary care physicians wrote over 11 million prescriptions for ADM, up from nearly 7.5 million Introduction 1 2 Chapter 1 in 1999–2000.10 These are impressive numbers for a country whose population is a mere 22 million. The total cost of ADM prescriptions in general practice in 2004–2005 was just under half a billion Australian dollars, nearly double the amount of 1999–2000.11 In the United States, the proportion of adults using ADM jumped from 2.5 percent in 1994 to 8 percent in 2002.12 In that country, with a population of around 307 million, the number of ADM prescriptions rose from 154 million in 2002 to nearly 170 million in 2005.13 Between 2000 and 2001 ADM sales in the United States increased from U.S. $10.4 billion to U.S. $12.5 billion, a rise of nearly 12 percent, cementing it as the highest selling drug category after cholesterollowering agents.14 It almost comes as a surprise, on viewing these figures, to learn that another, equally effective treatment for depression is available. Psychotherapy , in particular cognitive behavior therapy (CBT), has been subject to extensive trials that show its outcomes to be as good as those achieved with ADM. Ellis and Smith, funded by Australia’s national depression initiative beyondblue, conducted a meta-analysis of 107 randomized controlled trials of depression treatment. In a summary that echoes national guidelines in the United States and the United Kingdom, they reached the following conclusion: For the initial treatment, our meta-analysis shows there is little difference [in relative effectiveness] between the major pharmacological and psychological treatment options for mild to moderate depression.15 There is also emerging evidence that depressed people treated with CBT may have lower relapse rates compared to those who discontinue ADM after a successful response.16 Despite this, in Australia less than a quarter of those who present to a general practitioner with depression will receive a validated psychotherapy, and figures in the United States are likely to be similar.17 In trials comparing CBT and ADM, treatment outcomes are commonly measured with the Hamilton Rating Scale for Depression.18 It assesses the presence and severity of the typical symptoms of depression such as lowered mood, feelings of guilt, suicidal ideation, insomnia, anxiety, loss of energy or concentration, and indecision.19 It also measures somatic symptoms such as reduced appetite, weight loss, or changes in bowel habit. There are several versions of the scale. The 21-item questionnaire has a maximum...

Share