Informed consent: women need to know about the link between the pill and depression

Original article from the Conversation (May, 2018) by Jayashri Kulkarni and Caroline Gurvich

The introduction of the contraceptive pill in the 1960s was a major milestone for female empowerment. It allowed women to separate sex from procreation, and to increase their participation in work outside the home.

Now, more than 100 million women worldwide use the oral contraceptive pill to prevent pregnancy or control their menstruation.

But the pill and other hormone contraceptives are not without side effects. We usually focus on the physical health effects of the pill, yet the most common reason women stop or change the pill is mental health side effects.

Depression is one of the most prevalent and debilitating mental disorders in Australia, and affects twice as many women as men. It is estimated that one in four women will experience depression in her lifetime.

One in four Australian women between the ages of 18 and 49 use the pill, at any one time. But few are aware of the link between the pill and depression.

Types of contraceptive pill

There are many oral contraceptives available in Australia, with different types and doses of the hormones oestrogen and progesterone.

The most commonly prescribed is a combination pill, which contains an oestrogen to prevent ovulation, and a progesterone to reduce the chance of a fertilised egg implanting into the wall of the uterus.

Most combined oral contraceptives have a similar dose and type of oestrogen, but the progesterone types and doses vary widely.

There are also several progesterone-only contraceptives that do not contain oestrogen. These are known as the “mini-pill”, or injected contraceptive (“depot provera”), or the skin implanted “straw” (Implanon or Norplant).

Hormones and mental health

A recent review has shown that sex hormones have significant impact on brain areas related to emotional and cognitive functioning. Progesterones have been shown to induce depression, particularly in vulnerable women.

Synthetic progesterone (more than natural progesterone) has significant effects on the brain chemicals serotonin and monoamine oxidase, resulting in depression, irritability and anxiety.

There is a great deal of variation in the effects of hormone shifts on mood and behaviour. Some women are very sensitive to small shifts in oestrogen and progesterone; others aren’t.

What does the research say?

Our research has involved measuring the clinical impact of various types of oral contraceptive pill on mood and anxiety. Overall, we found woman taking the oral contraceptive pill were more likely to be depressed than non-pill users.

Women taking the pills with low amounts of oestrogen had more depression than those taking higher oestrogen dose pills.

Certain types of progesterone were more “depressive” than other progesterones, but the progesterone-only contraceptives were the most depressive of all the contraceptives.

A 2016 Danish study of more than one million women supports our clinical findings. The researchers found that, compared to non-users, women aged 15-34 who took the combined oral contraceptive pill were 1.23 times more likely to be diagnosed with depression and prescribed antidepressant medication.

Adolescents aged 15-19 who used combined oral contraceptives had an even higher rate of depression than older women. They were 1.8 times more likely to be diagnosed with depression than the non-pill using peers, and this increased to 2.2 times among adolescents using progesterone-only contraceptives.

The study concluded that depression is a significant potential side effect of hormonal contraceptive use, especially in adolescents.

It’s not all bad news

Emerging research by our group and others suggests the combined contraceptive pill may improve “verbal memory” or memory for words and language. This is thought to be driven by oestrogen, which has been shown to positively influence memory-related brain regions.

Research also suggests that pills containing progesterones that are structurally more like testosterone improve visual-spatial skills (traditionally, a male-dominant skill) and pill types containing other progesterones may worsen visual-spatial skills.

Finding the right contraception

There are many types of hormone contraceptives and their use needs to be tailored carefully for the individual, especially among adolescents. Women and their doctors need to be aware that hormone contraceptives can contribute to mental health problems, and women should return to their GP if they experience mental health side effects.

The development of new hormone contraceptives that don’t impact adversely on brain chemistry is well overdue. Women must have the right to control their fertility without compromising their enjoyment of life.

This revolution in our understanding of depression will be life-transforming

This revolution in our understanding of depression will be life-transforming

Original article from The Guardian by Edward Bullmore, April 29th 2018

The discovery of genes that are linked to the crippling condition throws up exciting new possibilities for its successful treatment.

Depression runs in families, we know. But it is only very recently, and after considerable controversy and frustration, that we are beginning to know how and why. The major scientific discoveries reported last week by the Psychiatric Genomics Consortium in Nature Genetics are a hard-won breakthrough in our understanding of this very common and potentially disabling disorder.

If your parents have been depressed, the chances that you have been or will be depressed are significantly increased. The background risk of depression in the general population is about one in four – each of us has a 25% chance of becoming depressed at some point in our lives. And if your parents have been depressed, your risk jumps by a factor of three.

However, controversy has long swirled around the question of nature or nurture. Is the depressed son of a depressed mother the victim of her inadequate parenting and the emotionally chilly, unloving environment she provided during the early years of his life? Or is he depressed because he inherited her depressive genes that biologically determined his emotional fate, regardless of her parenting skills? Is it nature or nurture, genetics or environment, which explain why depression runs in families?

In the 20th century, psychiatrists ingeniously teased out some answers to these questions. For example, it was found that pairs of identical twins, with 100% identical DNA, were more likely to have similar experiences of depression than were pairs of non-identical twins, with 50% identical DNA. This indicated clearly that depression is genetically heritable. But well into the 21st century, the precise identity of the “genes for depression” remained obscure. Since 2000, there has been a sustained international research effort to discover these genes, but the field has been bedevilled by false dawns and inconsistent results.

That is why the study published last week is such a significant milestone. For the first time, scientists around the world, with leading contributions from the UK’s world-class centres of psychiatric genetics research largely funded by the Medical Research Council at the University of Cardiff University, University of Edinburgh University and King’s College London, have been able to combine DNA data on a large enough sample to pinpoint which locations on the genome are associated with an increased risk of depression. So we now know, with a high degree of confidence, something important about depression that we didn’t know this time last year. We know that there are at least 44 genes, out of the 20,000 genes comprising the human genome, which contribute to the transmission of risk for depression from one generation to the next.

However, this raises at least as many issues as it resolves. Let’s first dwell on the fact that there are many risk genes, each of which contributes a small quantum of risk. In other words, there is not a single smoking gun, a solitary rogue gene that works like a binary switch, inevitably causing depression in those unfortunate enough to inherit it. More realistically, all of us will have inherited some of the genes for depression and our chances of becoming depressed will depend in part on how many and their cumulative impact. As research continues and even larger samples of DNA become available for analysis, it is likely that the number of genes associated with depression will increase further still.

This is telling us that we shouldn’t be thinking about a black-and-white distinction between us and them, between depressed patients and healthy people: it is much more likely that our complex genetic inheritance puts all of us on a continuous spectrum of risk.

What are these genes and what do they tell us about the root causes of depression? It turns out that many of them are known to play important roles in the biology of the nervous system. This fits with the basic idea that disturbances of the mind must reflect some underlying disturbance of the brain.

More surprisingly, many of the risk genes for depression also play a part in the workings of the immune system. There is growing evidence that inflammation, the defensive response of the immune system to threats such as infection, can cause depression. We are also becoming more aware that social stress can cause increased inflammation of the body. For decades we’ve known that social stress is a major risk factor for depression. Now it seems that inflammation could be one of the missing links: stress provokes an inflammatory response by the body, which causes changes in how the brain works, which in turn cause the mental symptoms of depression.

Knowing the risk genes for depression also has important implications for practical treatment. There have been no major advances in treatment for depression since about 1990, despite it being the major single cause of medical disability in the world. We need to find new ways forward therapeutically and new genetics is a great place to start the search for treatments that can cut through more precisely to the cause or mechanism of depression. It is easy to imagine how new antidepressant drugs could in future be designed to target inflammatory proteins coded by depression risk genes. It is exciting to think that the new genetics of depression could unlock therapeutic progress in psychiatry as well.

Finally, although I think these genetic discoveries are fundamental, I don’t see them as ideologically divisive. They don’t prove that depression is “all in the brain” or that psychological treatment is pointless. The genetics will be biologically pre-eminent but, as we understand more about what all these “genes for depression” do, we may discover that many of them control the response of the brain or the body to environmental stress. In which case, the treatment that works best for an individual patient could be a drug targeting a gene or intervention targeting an environmental factor such as stress.

In short, I believe that a deeper understanding of the genetics of depression will lead us beyond the question we started from: is it nature or nurture, gene or environment? The answer will turn out to be both.

Millennial on medication: time to break the silence about using antidepressants

Millennial on medication: time to break the silence about using antidepressants

Louis Hanson
The Age
December 13th 2017

About 18 months ago, when I was 20, I started taking medication – a combination of antidepressants and anti-anxiety pills. It was a long and arduous process – full of CAT scans, dieticians and psychologists – before I could even admit to my depression and anxiety. After exhausting all other avenues I came to the conclusion that perhaps medication was a necessary next step.

The lack of conversation surrounding antidepressants, though, made me apprehensive. This silence exists despite their prevalence. The Organisation for Economic Co-operation and Development’s 2013 snapshot of medication use by nation found that Australia was the second-highest prescriber of antidepressants in the world. The defined daily dosage of medication intake in adults more than doubled in Australia between 2000 and 2013.

So we’re using them but we’re not talking about them.

I asked some Millennial friends of mine who have found antidepressant medication effective but have only recently been public about it why they kept medication secret. “I was ashamed,” said one, “because I felt as if the inability to cope was a weakness that I didn’t see any of my other friends going through.”

“There isn’t an open discussion about it, [so] people feel quite scared,” said another. “It’s almost, like, to take this medication I’m … accepting ‘I’m a freak’.”

Antidepressants are certainly not for everyone. There can be negative side-effects including fatigue, weight gain, dry mouth, loss of libido, night sweats, diarrhoea, insomnia or nausea. I experienced a lot of night sweats and “brain zaps”.

And it doesn’t aways work. According to NPC MedicineWise, only about 50 per cent of those who take antidepressants report their symptoms have halved.

When I first started, I was lucky a friend warned me: “You get worse, before you get better.” I’m thankful that my friend told me this, because the first few weeks were tough.

But it did get better and they have been of use to me. I’m now in the process of weaning off my medication and I am thankful for the new perspectives it has given me.

So many of Australians are taking these medications; we should be talking about it too.

My friends and I are Millennials on medication, unapologetically so. We are going to talk about it so we can change the stigma surrounding medication.

This page reproduces an article on the The Age’s website.

Is Diet Linked To Depression? This Research Confirms It Again

Is Diet Linked To Depression? This Research Confirms It Again

The research reveals risk indicators for depression, and poor diet is just one of them.

Juliette Steen
The Huffington Post
October 13th 2017

When we’re sitting down to eat a meal, most of us don’t think about how food could affect our mental health. But more research is showing the connection between what we eat and depression, and new research has validated this.

Using a first-of-its-kind ‘Risk Index for Depression’ to assess how different behaviours affect the risk of depression, the research found that our diet is the most important contributor to mental health, followed by other factors like sleep and exercise.

The research, predominantly done through IMPACT SRC at Deakin University in collaboration with Swinburne University, confirms that depression is not caused by one simple factor or event, but rather various factors which, if identified for each young person, could help clinicians recognise the early signs of depression. In other words, the Risk Index for Depression is about prevention.

Considering depression is a global health concern — with one in six people to experience depression at some point in their life which will affect their wellbeing, personal relationships, work life and productivity — the Risk Index for Depression shows promise as a tool to add (or remove) direct or indirect risks.

To understand more about the risk determinants for depression, HuffPost Australia spoke to the Risk Index for Depression (RID) developer and Swinburne lecturer in the Department of Statistics, Data Science and Epidemiology, Joanna Dipnall.

“We utilised a large database from the U.S. which has a huge amount of information about people’s diet, lifestyle and self-reported medical symptoms,” Dipnall said.

“We spent time compartmentalising each of the risk determinants for depression, which include diet, lifestyle, environs, biomarkers and somatic symptoms, and for each of those we put into a probability of depression and built this into a structural model of the RID to see if we could determine an overall risk of depression and isolate the important elements.

“What we found confirms that depression is not a simple condition — it is complicated and multifaceted. It confirms that diet is one of the most important to asses the risk of depression. Diet has a direct path.”

In the research, under each main risk determinant there are predicted probabilities of depression. Lifestyle included sleep, weight and exercise; demographics included gender, rage and age; biomarkers included red cell distribution risk; somatic symptoms included pain, bowels and thyroid; and diet included fruit, vegetable and whole grain intake.

A key finding from the research is that a person is more likely to become depressed if their diet is poor, their lifestyle is erratic and they do not exercise.

“Interestingly, in somatic symptoms (which included symptoms of pain, liver and hearing) what dominated was the bowels. This also ties into diet,” Dipnall told HuffPost Australia.

“The team at Deakin University in the Food and Mood Centre are looking even further into this in isolation and have already found dietary fibre being central to gut health. My research is further confirming this.”

So, what’s comes next?

“This is the first stage. The RID is modular so we want to build on this model to include the important aspects of factors such as ‘stressful life event’,” Dipnall said.

“It’s not yet ready and needs more research, but ultimately the RID is about a predisposition to depression. What we want to do is be able to look at younger people and intervene based on their Risk Index with the best targeted intervention.”

Essentially, in the future clinicians may be able to use this tool to work out a young person’s predisposition for depression and identify their various individual determinants.

“Adolescents would go to their clinician and work out their Risk Index and where it’s most affecting their risk — is it their diet, lifestyle, stressful event?” Dipnall explained.

“A lot of people talk about depression and say, ‘You’ve got to do this to help your mood’, but nobody has really tried to bring it together to say, ‘Yes there’s diet, yes there’s lifestyle, and yes you have these somatic symptoms’.”

This page reproduces an article on the Huffington Post’s website.

Depression and mental health apps: How to tell the good from the bad

Depression and mental health apps: How to tell the good from the bad

Anthony Funnell
ABC News
December 6th 2017

There are currently more than 10,000 depression and anxiety-related self-help apps available to download, the American Psychiatric Association estimates. But less than 1 per cent have been professionally evaluated.

Cause for concern? Well, yes. But not a cause for depression, says Harvard Medical School’s John Torous, who leads the association’s working group on smartphone app evaluation.

In fact, he sees great promise in digital mental health technologies.

“We can begin to push evidence-based interventions through smartphones,” he says.

“And we have the potential to capture a lot of exciting real-time data that may give us clues about how people are feeling and how they are functioning in real life, in the community.”

Mental health apps, Dr Torous predicts, will eventually play an important supplementary role to conventional face-to-face therapy, with particular benefits for those living in remote areas.

Depression and social media

What is the relationship between depression and digital technology? Future Tense takes a look.

His enthusiasm is shared by Helen Christensen, the director of the Black Dog Institute at the University of New South Wales.

Professor Christensen says there is a growing body of research indicating that well-designed apps are as effective as face-to-face therapies.

Online tools designed to help alleviate or prevent mental illness take many forms.

Some work to give people a better understanding of the physical warning signs for anxiety, like an increased heart or breathing rate, for example. Others are used to help a person moderate or change their behaviour.

Professor Christensen and her researchers have been developing and evaluating various online applications, including apps that employ what psychologists call Cognitive Behaviour Therapy — known colloquially as the Talking Therapy.

“We are moving into a different arena where chat bots are getting more and more intelligent and they are capable of helping people to manage their own mental health,” she says.

But without any professional assistance, it can be difficult for those experiencing a mental health problem to find a digital tool that suits their specific needs.

Be strategic when choosing a mental health app

The American Psychiatric Association doesn’t recommend specific applications, but it has developed a four-level evaluation framework.

  • Step 1: Risk/privacy and security.
  • Step 2: Evidence.
  • Step 3: Ease of use.
  • Step 4: Interoperability (which refers to the ability to share the data generated by the app with a trusted medical professional).

Can your smartphone track your mental health?

Your smartphone knows a lot about you, but what about your mental health?

Dr Torous says many apps cleverly position themselves outside the medical regulatory framework in order to gather personal data and then share it with commercial interests.

“A lot of these are free because you’re telling the app what medication you are on, what therapy you are on, where you live, where you are going, and that information is being collected by the app and the app will legally own it,” he says.

He says it’s crucial that a person is confident in using the app they choose.

“There’s strong evidence that a lot of times people will download an app, but they will never use it more than once,” he says.

“No mental health app, no matter how safe and how effective, is going to be useful if it’s only used once.”

So what apps are out there?

Professor Christensen believes there’s currently a disconnect between consumers and researchers.

Many of the most popular apps, she says, are yet to be properly assessed, while those that have been evaluated tend not to have broad appeal.

Tips for choosing a good app

  • See if the app — or at least the principles it uses — is based in evidence
  • Be aware a high app rating doesn’t necessarily mean high quality
  • Look at who developed the app and consider whether they have a background or reputation in mental health
  • Check if the app has an adequate privacy policy

(Source: The Black Dog Institute)

“We have to remember this is a very new field. This explosion of apps is only really in the last three or four years,” she says.

“We need to work harder to co-design apps with those who use them.”

There’s also a need for greater consistency with the evaluation process, she argues.

Professor Christensen recommends choosing a mental health app in consultation with an accredited therapist. And a good starting place, she says, is the website Beacon — an online portal developed by the Australian National University.

All the mobile apps and websites listed on Beacon have been categorised, reviewed and rated by a panel of health experts.

SHUTi is another app evaluated by the Black Dog Institute.

According to Professor Christensen, use of the app has shown a reduction in suicide ideation and depression by using behaviour therapy to help improve sleep habits.

A third self-help initiative she recommends is called Brave. Brave is operated by beyondblue and has a specific focus on depression and anxiety in young children.

Online therapies developed by the Black Dog Institute include the interactive self-help websites moodgym, myCompass and BITE BACK.

Technology to help you sleep

When it comes to sleep, technology often gets a bad rap. But there are ways it can help you get better night’s sleep.

The next step for researchers and developers is ensuring the products they create are better integrated into systems of care, Professor Christensen says.

“The idea is that it’s not just out there for people to find, but we actually try to integrate it into areas in which people with mental health problems or depression symptoms do reside,” she says.

The Black Dog’s myCompass app, for example, is now being used by suburban doctors as a first step screening initiative when patients arrive at their local clinic for a regular consultation.

“We know that 90 per cent of people see a GP every year,” Professor Christensen says.

“So this is a good place to catch people and offer them an opportunity to do an online program we know is well evaluated.”

The news on depression is not all black

While demand for self-help apps is increasing, that shouldn’t be taken as a sign that levels of depression and anxiety are necessarily increasing too.

If you or anyone you know needs help:

Greater awareness of mental illness coupled with a decrease in stigmatisation has arguably made depression seem widespread, but Professor Christensen says she doubts mental illness rates are on the rise.

“My reading of it is that it’s not getting worse, though we don’t have very good datasets. So, we’ve only really done proper population data collection over two occasions. The last time was in 2008. And basically the prevalence of depression has not increased,” she says.

But that’s not to say the problem is diminishing. Latest research suggests that more than 50 per cent of all mental illness emerges before the age of 18.

In that vein, using smartphone technology to help counter or prevent the symptoms of mental illness seems particularly well-matched.

This page reproduces an article on the ABC News website.

A brighter view for mental health

A brighter view for mental health

Josh Jennings
The Canberra Times
October 27th 2017

Deakin University researcher Dr Olivia Dean’s depression treatment research could ultimately support prevention of the illness but she says she primarily derives her motivation from the immediate impact she can have on the psychiatric disorders she investigates.

“For people that have these disorders, prevention isn’t going to be something they’re interested in because it’s too late for that now,” says Dean. “While I think prevention should absolutely be the ultimate goal in future, we do need to be mindful of the people who already have the disorders.

“We want the best outcomes for them.”

Dean is a senior lecturer in medical science at Deakin University’s school of medicine.

She heads the clinical trial division of Deakin’s Centre for Innovation in Mental and Physical Health and Clinical Treatment (IMPACT).

 The research centre, based at Barwon Health in Geelong, investigates patterns of chronic disease, risk factors and novel therapies for psychiatric, musculoskeletal and metabolic disorders.

As director of the division, Dean leads clinical trials of novel therapies for psychiatric disorders.

This October, she was also awarded a fellowship from the National Health and Medical Research Council, in support of her research into new, biologically-based treatments for people with depression.

“The calibre of research in Australia is really high, so it’s rewarding to have received a fellowship, given that you’re competing against some brilliant minds,” says Dean.

Dean became senior lecturer in medical science at Deakin at the beginning of 2017. Since she began her research career about 15 years ago, she has held a variety of research roles at the University of Melbourne and Deakin.

She is also chairwoman of the Australasian Society for Bipolar and Depressive Disorders and she recently teamed with researchers to trial the impact of an antibiotic – primarily used to treat acne – on major depression.

She is also undertaking a clinical trial testing the rind of mangosteen (a tropical fruit) as a treatment for depressive symptoms.

The fellowship will help enable her to continue the advancement of her research and potentially benefit the next generation of antidepressant agents.

“In a year’s time we’d want to see some of the studies we have running come to fruition. We’re doing a lot of work looking at blood samples and the biology for factors that might contribute to some of these disorders.”

This page reproduces an article on the Canberra Times website.

Mediterranean diet can help in fight against depression, Australian study finds

Mediterranean diet can help in fight against depression, Australian study finds

Sophie Scott and Rebecca Armitage

February 3 2017

The Mediterranean diet is well known for its physical health benefits and it is now being hailed as the latest weapon in tackling mental health problems.

Key points:

  • The diet improved the mood of about a third of participants
  • Researchers say it highlights the need for better diet support for patients
  • But they warn the diet should not replace traditional treatments

Researchers at Deakin University have found the diet can help those suffering from severe depression.

They put dozens of patients with major depressive disorders on a Mediterranean-style diet rich in wholegrains, legumes, fresh fruit and vegetables, olive oil and nuts.

After 12 weeks of healthy eating, researchers said one third of the participants reported a significant improvement in their mood and symptoms.

The results of the study were recently published in the international journal BMC Medicine.

Professor Felice Jacka, director of Deakin University’s Food and Mood Centre, said the Mediterranean diet had been credited with improving cardiovascular health, reducing the risk of diabetes and increasing longevity.

“We already know that diet has a very potent impact on the biological aspects of our body that affect depression risks,” she said.

“The immune system, brain plasticity, and gut microbiota seem to be central not just to our physical health, but also our mental health.

“And diet, of course, is the main factor that affects the gut microbiota.”

Professor Jacka randomly selected 31 participants to embrace the Mediterranean diet and reduce their intake of sweets, refined cereals, fried food and sugary drinks.

What is the Mediterranean diet?

  • Based on the eating habits of people living in Italy, Spain, Portugal and Greece
  • It’s rich in olive oil, vegetables, fresh fruit, wholegrains, nuts and legumes
  • Moderate intake of fish, poultry, dairy products and red wine
  • Low intake of pasta, red meat, and sugar
  • It’s been shown to lower risk of cardiovascular disease, diabetes and cancer

Another 25 participants received social support which involved weekly visits from researchers.

Only 8 per cent of those in the social support group showed improvement in their symptoms.

One of the participants who changed her diet, Sarah Keeble, described the program as life changing.

“I felt clearer in my mind. I felt balanced. I felt happier. I actually had a lot more energy. I felt I could really kick this in the butt,” she said.

“It’s not going to cure depression, but you can certainly handle it very well.”

Ms Keeble has continued the Mediterranean diet after finishing the program and is now doing a diploma in health science.

“I got so motivated because I felt so much better, better than I had in so long,” she said.

“I’d like to help people in this situation where they think there’s no hope.”

Diet not a replacement for traditional treatments

Professor Jacka said people suffering from depression should not replace therapy and drug treatments with the Mediterranean diet.

What the study participants ate:

  • Per day: Six servings of vegetables, five servings of wholegrains, three servings of fruit, two servings of unsweetened dairy, one serving of raw, unsalted nuts, and three tablespoons of olive oil
  • Per week: Three servings of lean red meat, two servings of chicken, up to six eggs, and at least two servings of fish
    Extras: No more than three servings per week of sweets, refined cereal, fried food, fast food and soft drink
  • Alcohol: No more than two glasses of red wine a day, only with dinner

“Most of the people in our study were receiving psychotherapy or pharmacology treatment. But it’s something that supports any other interventions designed to help depression,” she said.

Professor Jacka would like to see dietitian support made available to those experiencing depression.

“It’s not a stretch to consider that people coming to a doctor with depression might have a referral to a clinical dietician,” she said.

“Weight loss is not a factor in this particular case, but we hope we’ll help to change the public’s ideas of why it’s important to eat well – both from a prevention and a treatment point of view.”

This page reproduces an article on the ABC News website.

The pendulum may have swung too far in mental illness

The pendulum may have swung too far in mental illness

Jill Margo
December 3, 2014

It’s time to stop saying almost half of all Australians suffer from a mental illness at some time in their lives. Although this is the official view, it depends on floppy definitions and figures.

Drawing on figures from 2007, the Australian Bureau of Statistics tells us “almost half (45 per cent) of Australians aged 16 to 85 reported they would have met the criteria for a diagnosis of a mental disorder at some point in their life”.

This is quite different to glibly saying, as many mental health campaigners do, that half of us suffer a mental illness at some time.

On the numbers, Jon Jureidini, professor of psychiatry at the University of Adelaide, believes the touted 50 per cent results from the conflation of two populations.

He says 1 to 2 per cent of the population suffers from severe mental illness that requires psychiatric help.

Community surveys show that in a given year, 15 to 20 per cent suffer a level of distress that meets the criteria for a mental disorder. However, there is little evidence they need more psychiatric help than seeing their GP or a counsellor, or doing nothing.

“The problem is that people translate the 15 to 20 per cent in any given year as 15 to 20 per cent at any given time. But a lot of these episodes are self-limiting and resolve within the year, so the number of people suffering at any given time is significantly lower.

“The assumption is also made that the 15 to 20 per cent have the same sorts of needs and will benefit from the same sorts of interventions as the 1 to 2 per cent.”

Jureidini says the 50 per cent is absurd, and can easily slide to 100 per cent.

“If you want to define every episode of significant distress that someone experiences as an illness, then we all suffer from self-limiting mental illness at some time in our lives.

“Taking distress seriously doesn’t amount to giving it a medical label and giving medication for it,” he says.

The number of Australians who may be mentally ill has grown as the definitions of mental illness have expanded.

The ABS describes mental illness as “a number of diagnosable disorders that can significantly interfere with a person’s cognitive, emotional or social abilities”.
Naming or shaming?

The definitions of mental illness are global, but their floppiness is evidenced by the fact that in Britain, officially only 25 per cent of people suffer a mental illness in their lifetime.

Or is it that we have double the trouble?

But there is a positive side to broad definitions. They help destigmatise the illness and the suffering.

The fact that mental illness is so common makes it easier for people to volunteer that they have an issue and easier to seek help.

Some are greatly relieved to receive a diagnosis. “Thank goodness you’ve got a name for this, and a treatment,” is a sentiment that is often heard.

This helps people understand their condition and perhaps find some community support. But then, on receiving a diagnosis, some feel they have a label that will dog them for life.

For others, a label can be a useful excuse. Jureidini says when a boy is labelled with ADHD, the parents feel less blamed and the boy feels he has an explanation. “But then you hear him saying ‘Oh, I couldn’t control that. That was my ADHD’. ”

Labelling often brings a loss of autonomy. A key word in mental health, autonomy is about a person’s ability to be self-governing and make decisions that are informed, rational and in accordance with their values.

“The difference between good psychiatry and bad psychiatry is whether I increase or decrease my patients’ autonomy,” Jureidini says.

“Feeling worse but being more autonomous is a superior state to feeling better and being less autonomous.”
Medication paradox

Jureidini also points to a paradox in the push to medicate more people.

“Take a man in his 50s who becomes depressed out of the blue. He’s invited to think of it as biological and adds antidepressants to the booze he is already drinking to excess, which everyone, including his doctor, is turning a blind eye to.

“The alternative is to reflect and think back regretfully about how he gave so much priority to work, and look at the effect on his relationship with his kids and say ‘I am really disappointed at how my life turned out’.

“It could be good for him to live with this distress for a few months and maybe begin to build meaningful relationships with his grandchildren rather than taking a few pills and getting on with being a dead-shit father.”

The paradox lies in the stigma. Jureidini says people take a dimmer view of mental illness caused by brain chemistry than by social and environmental factors.
Trivialising problems

The broadening definitions bring negatives, particularly for those with milder forms of mental illness.

Paul Biegler, winner of the Eureka prize for his book The Ethical Treatment of Depression: Autonomy through Psychotherapy, says many people are unnecessarily put on medication when they are going through variations of normal experience, such as loss in the form of grief, relationship breakdown or financial failure.

“We trivialise these experiences and treat them as a derangement in brain chemistry that can be normalised with a pill. Perhaps a better approach might be to look for the meaning in what has happened and address it more functionally,” he says.

When people are given anti-depressants for such conditions, they are encouraged to take a biological view of their illness, which can rob them of autonomy. Rather than working out a way to resolve or accept the circumstances, they take a pill.

Biegler, a physician and an adjunct research fellow at the Centre for Human Bioethics at Monash University, says people treated with psychological therapy, such as cognitive behavioural therapy, are less likely to accept a biological model of their illness.

Rather, they tend to see their condition as a response to stressors in their environment and are more motivated to target them. “They are more autonomous in getting through their current and their future episodes of depression,” he says.
A primitive science

Despite questions about their efficacy for mild to moderate depression, antidepressants are often the first line of treatment for these conditions.

And Australia is a very high user. Last year, an Organisation for Economic Co-operation and Development survey showed that out of 33 countries, Australia was the second-biggest user per head of antidepressants. Iceland was first.

The survey showed almost 9 per cent of Australians were prescribed some form of daily antidepressant. A decade earlier it was half that.

“I think 9 per cent is an excessive amount of prescribing,” scientia professor and head of the school of psychiatry at the University of NSW, Philip Mitchell, says.

“In any 12 months, some 5 per cent of Australians experience depression and some of it is mild and does not require medication.”

Much prescribing is done in the general practitioner setting, often under pressure from patients. Mitchell points to the structural difficulty of remuneration and time in general practice.

“The system is antithetical to coming to grips with the patients’ experience and distinguishing clinical depression from a difficulty adjusting to difficult circumstances.”

Mitchell, also a professorial fellow at the Black Dog Institute, is concerned about the 50 per cent.

“Any condition where you start to talk about that level of prevalence in the community starts to worry me.”

It has not been well communicated that the figures include mild, moderate and severe disease. Formal diagnostic criteria are used because a degree of impairment or dysfunction exists, but some of it is mild illness, which requires watching and waiting without active intervention.

So what does the 50 per cent mean? “It means that a trained interviewer in the community would say at some stage in their life, these people have had some symptoms that fulfil the diagnostic criteria.”

It does not mean that half of all Australians have needed to go through the mental health system.

Our definitions and criteria are largely drawn from The Diagnostic and Statistical Manual of Mental Disorders. Known as the DSM, it is American and serves as an almost universal authority for psychiatric diagnosis. With each new edition, new diagnostic categories emerge.

The benefit is that it allows people to know what they are talking about in different countries. In this regard, Mitchell says it has improved the reliability of diagnosis. But he says the big issue is about its validity – its ability to validate reality to the diagnosis.

“I see these things as evolutionary. Today, for most of the disorders we don’t have a biological test. We are dependent on pattern recognition in dealing with these complex and subtle disorders and this can be a problem.

“We look for signs and symptoms that cohere, that make a syndrome. This is where medicine was in the mid-19th century. It had syndromes but few biological tests.

“Psychiatry will evolve. I believe we will look back in 50 years and say this was very primitive. But we can only do the best we can with existing knowledge.”
Too much goodwill

At the moment, however, our prescription rate is rising fast. Last year a study in the Australian and New Zealand Journal of Psychiatry showed that in the decade to 2011, there was a 58 per cent rise in dispensing psychotropic drugs.

Ray Moynihan, senior research fellow at Bond University’s Centre for Research in Evidence-Based Practice, believes the pendulum has swung too far in mental illness.

“There have been extremely valuable campaigns in Australia to destigmatise mental illness, but some zealous advocates have created the appearance of a giant epidemic.

“When you label every second person as having had a mental illness, you run the risk of undermining the debilitating and severe nature of genuine psychiatric illness.”

In our attempt to help, we are pushing the boundaries too wide and labelling too often. Rather than a conspiracy, Moynihan says it’s an accident of too much goodwill – a road paved with the best of intentions!

This page reproduces an article on the Australian Financial Review’s website.

Australian researcher discovers promising treatment for depression

Australian researcher discovers promising treatment for depression

Nicky Phillips
The Sydney Morning Herald
January 25, 2015

David* has lived with depression on and off since he was 19. At times over the past 15 years it has arrived without warning, whereas other episodes have been triggered by a stressful event.

Having tried various treatments, including counselling and medication, all with some degree of success, he enrolled in the trial of a promising new therapy that combines gentle brain stimulation using weak electric current and thinking exercises.

During his 15 sessions over three weeks last year David found his mood unchanged, but about a month later noticed he was feeling good.

“Then in June and July I had quite a few stressful situations and in the past I probably would’ve fallen into a heap. However, I found I had this new resilience to get through them, which was really surprising,” he says.

David wasn’t the only one who was surprised. Dr Rebecca Segrave, the neuropsycologist and researcher who came up with the idea to combine gentle brain stimulation with brain training, was so shocked by the trial’s results she re-checked her figures several times.

But the results were real, and she could see improvements in her patients.

“It’s really thrilling to sit with someone, one on one, and hear how their life has improved,” she says.

In a pilot study of about 30 participants, almost half who received the combined therapy – rather than a single treatment or a placebo -improved, and about a third were in remission by their three-week follow-up.

“That means their symptoms of depression had gone completely,” Segrave says.

About one in six people will experience depression at some point in their lifetime, and of those almost 30 per cent will not respond to standard treatment such as medication, counselling and cognitive behaviour therapy.

Psychiatry professor Paul Fitzgerald says life for these patients can be very disabled. And they have high rates of suicide.

“For many years we have been hopeful that the pharmaceutical industry would come up with solutions, that there would be new drugs that would be better than the ones we already have,” Fitzgerald, who works with Segrave at the Monash Alfred Psychiatry Research Centre, says.

“But many drug companies are choosing not to invest in new drug treatments for depression, so we really need other approaches,” he says.

The brain training part of Segrave’s encouraging new treatment works by exercising a specific brain region known as the dorsolateral prefrontal cortex. This smallish area at the front of the head is a critical control-centre for thoughts and emotions. In people with depression it is often under-active.

This explains why people with the condition have trouble controlling their emotions and disengaging the negative thoughts swirling through their mind, Segrave says.

“The area that would normally regulate that and put the brakes on is the dorsolateral prefrontal cortex, but it’s under-active, so not able to control and regulate their thoughts, particularly their negative thinking.”

Much like exercising muscles makes them stronger, research has found brain training based on computer-generated thinking activities can re-activate neurons in this region, reducing the severity of depression symptoms.

To maximise its effect, Segrave combines it with a gentle form of brain stimulation, known as transcranial direct current stimulation (TDCS).

“People have gotten particularly excited about it because it’s very safe, it’s inexpensive and it’s portable,” she says.

TDCS is  milder than the more familiar electroconvulsive therapy (ECT), also used to treat severe depression.

While researchers have been exploring brain stimulation using electric currents as a treatment for several mental illnesses for decades, what began as rather crude experiments have evolved into a sophisticated field.

Another technique to stimulate the brain applies magnetic coils that create electrical pulses to a small region of the brain. It has become a well-established treatment for depression.

A recent experiment at Melbourne’s Alfred Hospital found transcranial magnetic stimulation could offer relief to severely depressed patients after three-days of intensive treatment.

Segrave was drawn to TDCS however because, while it has been shown to improve depression symptoms, there is also evidence it can enhance a recipient’s thinking skills. Repeated sessions have other downstream effects on the brain, strengthening connections between neurons, she says.

“We apply stimulation to the same region during the training to gently pre-activate that area of the brain while the training is going on.”

The study found the two techniques combined had a much greater impact on reducing patients’ depression severity, with lasting effects.

Fitzgerald says the combined therapy has a lot of potential. “We’re very pleased with the results,” he says.

Segrave applied for money from the National Health and Medical Research Council, the country’s main medical research funding agency, to run a larger trial this year. While the project received positive reviews, it was not funded.

“It was considered good science, rigorous and worthy of funding, but there’s not enough money to cover all the science that’s worthy of funding,” she says.

She is looking for other donors, and will spend months applying for government funding again this year, because she believes in the treatment.

“I’m committed to trying to get more funding because the initial results suggest this could be an exciting new treatment for depression.

“It’s expensive to test new treatments, and the NHMRC is one of the only funding bodies that can give you enough money to ask the hard questions about whether it really works.”

* name withheld

This page reproduces an article on The Sydney Morning Herald website.

Mental health funding crisis: doctors planning to quit over lack of resources

Mental health funding crisis: doctors planning to quit over lack of resources

Amy Corderoy
The Age
March 9, 2015

  • Survey of psychiatrists reveals emerging crisis
  • Lack of transparency around budgets, lack of services in some areas
  • Authorities aware of the problem, and trying to fix it

Mental health care is heading towards a crisis in NSW with one quarter of the state’s psychiatrists considering leaving the public system this year because of “grossly inadequate” resources and low morale. Mental Health Minister Jai Rowell says the government is committed to meeting community needs.

The exodus comes amid allegations that some local health authorities are systematically siphoning off mental health resources and refusing to fill key clinical positions so money can be diverted to other areas.

Sources have told Fairfax Media that immense pressure being exerted on resources, particularly in some rural areas and parts of western Sydney where needs are greatest, with people suffering acute psychiatric crises often left without help until the problem escalates and police are called.

However, the government said it takes the problem extremely seriously and has introduced ongoing auditing to prevent the diversion of funds.

Paul Fanning, who worked as a director of mental health services in NSW for 23 years, said local health districts had been forced to find efficiency savings at the same time as improving treatment times.

“To me there is a straight-line relationship between the financial state of the districts … and the degree to which mental health is impacted,” he said. “Where we mostly see that is in community mental health services … where an enormous amount of work is needed in following up on people when they are discharged from hospital and doing early intervention work so things don’t escalate into a crisis.”

In its inaugural report last December, the Mental Health Commission said if the siphoning of funds away from mental health services was not addressed within two years it would consider asking the government for independent auditing powers. The commission, which started in 2012, was set up by the NSW government to advise on how it should improve mental health care across the state. No-one knows exactly how much money is being lost, although one 2009 report seen by Fairfax Media estimated so called budget “leakage” could be as high as $20 million annually.

Survey of psychiatrists paints ‘grim picture’

Doctors’ groups were so concerned they surveyed the state’s psychiatrists, with the interim results showing more than half believe resources have decreased over the past year and a third say they are “grossly inadequate”. One quarter are likely to leave the public sector this year if nothing changes.

AMA councillor and psychiatrist Choong-Siew Yong said it painted a grim picture, and more needed to be done to ensure psychiatrists were included in the health district decision-making so they could protect resources.

“Psychiatrists look after some of the most vulnerable groups in the state … but historically mental health has had less funding in relation to need and there is still a huge catch-up to do”.

The exclusive survey of more than half the psychiatrists in the public system – 250 doctors – undertaken by the NSW branches of the AMA, the Australian and New Zealand College of Psychiatrists and the Australian Salaried Medical Officers’ Federation, also found 44 per cent of doctors believe positions are deliberately left unfilled and one third believe the number of doctors employed in their area has declined.

Dr Yong said the scale of the problems varied from district to district, but more resources were needed everywhere to improve morale.

Lack of transparency around budgets, lack of services in some areas

Alan Rosen, a professorial fellow at the University of Wollongong and a clinical associate professor at the University of Sydney’s Brain & Mind Research Institute, said he believed tens of millions of dollars that could be spent on community workers and other treatments was being siphoned out each year, often through excessive corporate fees and charges, with the problem increasing in some areas after greater control was given to local areas over budgets.

“If we don’t do something we are going to end up with an inquiry into the disasters,” he said. “It’s time for the government to act”.

The differences in approaches between local health districts also meant a person’s ability to access services could depend simply on where they lived and what time of day they became sick.

“In NSW we do very little consistently and on an equitable basis around the state, and based on the building blocks of evidence,” he said. “We don’t even have out-of-hours crisis teams in every catchment … Crises occur maybe a third of the time in weekday periods, a third at night and a third on the weekend, so you need your crisis teams to work 7 days a week, 24 hours a day.”

Last month Fairfax Media revealed the number of people with mental illness dealt with by police had grown massively over the past decade, with a lack of mental health services in the community partly to blame.

However, the director of mental health and drug and alcohol for NSW Health, Peter Carter, said major costing reviews were undertaken twice yearly to examine corporate charges.

He said that over the past three years corporate and other related costs have ranged from around five to six per cent, although he acknowledged there was “volatility” between districts the ministry was trying to abolish.

However, Professor Rosen disputes the figures, saying it does not accord with what he has heard from clinicians working in the area.

Ministry aware of the problem, and trying to fix it

The Ministry of Health says it is working hard to fix the problems, including recruiting more staff in areas where it has been hard to attract qualified people.

The chief psychiatrist of NSW, Murray Wright, said the ministry took the staff survey very seriously, and he intended to discuss the issue further with the staff professional bodies and follow up with individual districts about any concerns.

“Local health districts have assured me that they are implementing recruitment strategies to deal with what are, in many instances, long-term challenges in recruiting and retaining skilled psychiatrists.”

Minister for Mental Health Jai Rowell said since its election the government had ensured mental health budgets were listed separately in service agreements with the local health districts.

“The NSW Government is committed to meeting community need for mental health care services,” he said.

“This financial year alone the NSW Government invested $1.62 billion in mental health – a record spend on our state’s mental health system.”

This page reproduces an article on The Age website.