BRITISH BROADCASTING CORPORATIONÌý
RADIO SCIENCE UNITÌý
CASE NOTES 4. - DepressionÌýÌý
RADIO 4Ìý
TUESDAY 31/08/04 2100-2130Ìý
PRESENTER:
MARK PORTERÌý
REPORTER:
TRICIA MACNAIRÌý
CONTRIBUTORS:
TIM KENDALL
RAJ PERSAUD
ISOBEL HEYMAN
ADAM SAMPSON
SHARON BULLOCKÌý
PRODUCER:
HELEN SHARPÌýÌýÌý
NOT CHECKED AS BROADCAST
PORTER
One in five of us will experience at least one episode of depression at some stage during our lives. Sharon Bullock's problems started in her early 20s.Ìý
BULLOCK
Common symptoms really - just not wanting to get out of bed, not wanting to do anything, go anywhere, see anybody. I felt that my life was in such a mess, I wasn't very good company because I had nothing nice to say because life was so bad.Ìý
PORTER
But it's not just adults who are affected. As many as 1 in 40 British primary school children, and 1 in 12 adolescents, are thought to be clinically depressed at any one time. And, if antidepressant use is anything to go by, it's a growing problem - GPs issued nearly 28 million prescriptions for antidepressants last year - more than double the 13 million dispensed in 1995.Ìý
But have we become over-dependent on medication at the expense of other, more time consuming interventions, such as counselling, support and psychotherapy?Ìý
And what about children? The Committee of Safety of Medicines has advised against the use of some of the more commonly prescribed antidepressants, in children and adolescents, because of lack of evidence that they actually help, and concerns that they may increase the risk of self-harm and suicide. So what should we be offering depressed young people?Ìý
I'll also be finding out how where you live influences your chances of getting the help and support you need to beat depression. And I don't mean the lottery of postcode prescribing - more what happens if you are depressed and don't have a postcode - at least not of your own.Ìý
BULLOCK
The worst point was when I was in the homeless accommodation, I know you can't always have something in your life to look forward to, to pick you up but yeah in the homeless I think was the worst that it's been because you never knew what the end result was going to be - where you were going to be put, your future was just in someone else's hands and it's quite a scary thing.Ìý
PORTER
My guest in the studio today is Dr Tim Kendall, he's deputy director of the Royal College of Psychiatrists Research Unit.Ìý
Tim, what's the difference between depression and unhappiness?Ìý
KENDALL
Well there's a spectrum. The difference really amounts to - in depression - people have an almost complete absence of good feelings. On top of that when things get more severe their body starts to react differently, so they get very wound up at times, tend to feel often agitated, sleep gets pretty poor, go off their food, sometimes lose weight and eventually can get to the point where they're just - they're almost moribund - can't move.
PORTER
What triggers depression?Ìý
KENDALL
Lots of different things but characteristically it's loss event - it's losing a husband, losing a child, losing a boyfriend, losing self-esteem - that sort of thing. Some people come in and say - nothing's happened - but more often than not if you delve around and talk more and get to know them better eventually they'll tell you what's happened.Ìý
PORTER
Who's most at risk?Ìý
KENDALL
Well typically you're talking about people who are either most disadvantaged or have had very difficult lives. Depression in adults and children tends to be more often associated with people who are in poor circumstances, people who've suffered physical or sexual abuse as children - the usual things that you think - adversity.Ìý
PORTER
Are women more likely to develop it than men?Ìý
KENDALL
Depends on the circumstance. In marriage women more than men, in divorce it's men more than women. Different situations suit people differently.Ìý
PORTER
I think it's fair to say that we all understand that if you have a problem with your lungs you get a cough, so it would seem fair to assume that if you've got a problem with your brain you get a change in the behaviour. So is there actually any demonstrable abnormality in the brains of people who are clinically depressed?Ìý
KENDALL
Well there's none been demonstrated, there's lots been speculated and without getting too complicated about it there are a set of transmitters in your brain called monoamines which are thought to be out of balance. Now having said that most of the evidence from that has come from researching drugs which might improve people's mood ...Ìý
PORTER
These are things like serotonin - these sorts of chemicals in the brain?Ìý
KENDALL
Yeah serotonin but also things like - in early research on amphetamines showed that amphetamine increased the release of certain types of monoamines, seratonin reuptake inhibitors, like paroxetine and so on, they increase monoamine concentrations in your brain.Ìý
PORTER
So we know what antidepressants do - they raise these concentrations - so depression must be a problem with these neurotransmitters we think.Ìý
KENDALL
That's often what people have thought.Ìý
PORTER
You don't look impressed.Ìý
KENDALL
Not very impressed no. I think the - a huge amount of the research into this is sponsored by drug companies who have a very clear interest in profit, quite rightly, that's what drives the market, any market, but because so much research is undertaken by people who are funded by drug companies, inevitably the areas that they research are going to be areas that are of interest to drug companies. So we tend not to research the social causes so much as we do the biochemical possibilities.Ìý
PORTER
So we're focused on the neurochemistry - these neurotransmitters - and raising the levels or altering the levels with antidepressants rather than looking at perhaps biological, psychological pathways ...Ìý
KENDALL
Yeah indeed, psychological and social pathways and indeed there's a paucity of research around the psychological and social methods.Ìý
PORTER
We are definitely prescribing far more antidepressants than we used to, is that a sign that depression itself is more of a problem or are we picking it up more often?Ìý
KENDALL
Very difficult to tell. Good historical studies are very hard to come by in any field within medicine. I mean there are some reasonably good ones around self-harm which appears to have increased of recent times but there's no clear evidence that that's because people are more depressed. We do know that more antidepressants are being prescribed and I think as you said earlier three fold increase over a decade. That is likely to be, at least in part, because that's all that's available - so if somebody comes along to a GP and says I feel depressed, if the GP really catches on that they are depressed that's the easiest and most straightforward thing to give. It's also true that the advertising that comes through a doctor's door will focus their mind on the latest types of antidepressants and will make claims of the clear effectiveness of an antidepressant.Ìý
PORTER
Well we'll stop it there for the moment Tim.Ìý
Dr Raj Persaud is the Gresham Professor for the Public Understanding of Psychiatry and I asked him for his thoughts on the recent growth in antidepressant use.Ìý
PERSAUD
The problem with something like depression is first of all that it's very difficult to diagnose correctly and I suspect that a large number of people are taking antidepressants who probably shouldn't be taking them and also a large number of people who should be taking them aren't taking them. So you enter a very grey area, grey territory, over the problem which starts off with, which is that there's no blood test for depression, so doctors find it quite difficult to make the diagnosis. And the diagnosis is something that isn't quite as clear cut and fixed as it might be for the rest of medicine.Ìý
PORTER
But does it matter if we're over-prescribing antidepressants, if we're using them in people who perhaps don't need them and will get better eventually on their own and are basically unhappy or reacting to some particular event that the tablets aren't going to change - does it matter that they're on them?Ìý
PERSAUD
It matters always with any treatment that people shouldn't be receiving it inappropriately for several reasons. One of which is there's no treatment in medicine that doesn't have side effects and doesn't have dangers. And particularly with something like depression where someone maybe suicidal and a doctor may be giving them, in the form of a prescription, with the means by which the patient might kill themselves it becomes particularly important to make a careful assessment as to whether the person should really be taking that tablet or not.Ìý
PORTER
What sort of side effects do you see in day-to-day clinical practice in people who are taking antidepressants?Ìý
PERSAUD
Well with the newer drugs, the newer - what are often referred to as SSRIs, it's actually they're amazingly clean, is the word that pharmacologists would use. Many people take these drugs and experience no side effects whatsoever. Sometimes people might get a tremor, they might get a bit of blurred vision. With the newer drugs - SSRIs - because serotonin receptors, the ones they act on, are often found in the gut, there are a lot of gastrointestinal side effects like nausea, for example, is a very common side effect and sometimes a bit of diarrhoea but often that wears off after a few days, so they're very clean indeed.Ìý
PORTER
And what sort of evidence do we have that these newer generation drugs - they're obviously better tolerated but are they actually anymore effective than the older tablets?Ìý
PERSAUD
There is, I think, very little evidence that the newer drugs are anymore effective than the older drugs. Their major advantages are that they are cleaner - you get many fewer side effects - and also their dose is easier to get right because usually there's just one dose so it's very difficult for a doctor to get that wrong. Whereas what was the chronic problem with the old antidepressants, although they were often being prescribed with the right patient they were often being under-prescribed at way too lower dose. Interestingly enough if you look at the psychiatrists who specialise in the treatment of depression and the kind of doctor you might get to after you've been through a layer of other doctors, they often go back to the older drugs when they're treating very chronic, very resistant depression and often we have a lot more experience with the older drugs, in terms of using them in combinations with other medications as well. So I think that it would be dangerous to ignore the fact that there's very little difference in efficacy and there's some advantages to the older drugs. For example, with the older drugs because there is a dose range you can push the dose up much higher and get a benefit as a result of that than you can with the newer drugs.Ìý
PORTER
Now when you come to stopping treatment there's been a lot of adverse publicity recently, particularly with the newer drugs - the SSRIs - that patients have to be weaned off them slowly otherwise they get withdrawal effects and in fact there's been a lot of talk about them being "addictive" and certainly in practice it is a problem, can be a problem with some drugs in some patients.Ìý
PERSAUD
I think that the notion of withdrawal and addiction - these are quite complicated notions. Certainly there is some evidence that on people with paroxetine or seroxat, and interestingly this is an antidepressant, one of the newer ones, where the dose often is pushed up, often with great benefit for the patient, but maybe some of those patients who are on higher doses, sometimes a doctor or a GP stops the medication suddenly and because they're on a higher dose there is some evidence that some of those patients do experience a kind of withdrawal syndrome, that doesn't necessarily mean that they were addicted to the medication in terms of becoming dependent because often the evidence says that if they're left alone, these patients recover very rapidly from this withdrawal syndrome but it can be a bit of a shock to the system if the patient isn't used to it.Ìý
PORTER
What sort of symptoms do they get?Ìý
PERSAUD
Well oddly enough one of the words that patients often use are shocks, they feel sometimes like they're electric shocks travelling through their bodies and sometimes they feel a resurgence in anxiety. But, as I say, generally speaking these symptoms are not very severe and they usually disappear left unattended to. However, I think there are a group of people what's really happening is they're basically re-experiencing a relapse of their depression and it's been described in a sense where the patient becomes alarmed at the notion they're addicted to their antidepressant. One of the number one reasons why patients don't want to take antidepressants is because they're worried that these medications are addictive - they are not at all addictive. However, if your depression has been under-treated and if you're stopping the medication too early then you will experience a relapse in the depression.Ìý
PORTER
And assuming your depression has been properly treated but you are one of the group who suffers real withdrawal effects is there anyway that we can minimise those?Ìý
PERSAUD
Usually you have to restart the medication and then come off it a bit more slowly and that usually works very effectively.Ìý
PORTER
Dr Raj Persaud.Ìý
You're listening to Case Notes, I'm Mark Porter and I'm discussing depression with my guest consultant psychiatrist Dr Tim Kendall.Ìý
Tim, how effective are antidepressants?Ìý
KENDALL
I think the received wisdom, and I think up until the last year or so, most consultant psychiatrists would prescribe antidepressants with the idea that these would probably get 60-70% of people better and that's what you tell patients when they came in and that always helped.Ìý
PORTER
You say received wisdom. I know that there's been some new work, in fact that you've been involved in, that suggests that might not be the case, we'll come back to that later. In the meantime what are the alternatives to antidepressants - if we don't use pills what else can we do to help these people?Ìý
KENDALL
Well there are lots of other possible treatments and the difficulty - when I say possible the real problem is has the research been done to show that they work? And I think we do have to do that with everyone that we're - every intervention that we're suggesting. But there are talking therapies, some which are specifically designed for depression, some which are more generic - like counselling. There are also physical things you can do like exercise. It's not massive amounts of evidence to support that but there's enough for us to think that that might be a useful thing for some people who are depressed.Ìý
PORTER
Well one of the biggest controversies surrounding medication, is its use in children. Around 40,000 under 18s are prescribed antidepressants, despite the fact that none are licensed for use in children in the UK. But how do we know that such "off licence" is safe? Particularly in light of recent guidance from the Committee of Safety of Medicines advising doctors not to use some types, including paroxetine or Seroxat, because they don't seem to work in children, and they may increase the risk of suicide and self-harm. Isobel Hayman is a child and adolescent psychiatrist at the Maudsley and Great Ormond Street Hospitals.Ìý
HAYMAN
We do have a very mixed bag of evidence about whether these drugs are effective in young people and whether they're safe in young people and I think it's fair to say that the jury is still out about weighing up the benefits and risks. So I would absolutely agree with you we have to be very careful about making sure that overall we're doing good not harm if we think about giving these medicines to young people.Ìý
PORTER
Do you think our experiences with the SSRI family will alter the way we look at other drugs, perhaps we're maybe more critical towards the products that we're using in teenagers?Ìý
HAYMAN
I think there's a huge need for more studies in young people, people wonder whether it's ethical to do studies in children and I would make a strong case that it's not ethical not to do studies - double negative there - because if we don't do the studies all we're subject to is people's very strongly held beliefs. And for example there was a trial published this week in the journal of the American Medical Association which compares fluoxetine with a psychological treatment, CBT - cognitive behaviour therapy - and with a combination of CBT and fluoxetine in young people showing that actually fluoxetine is more effective than placebo and actually the combination of psychological treatment and fluoxetine was the most effective of all. And in fact in that sample CBT - psychological treatment - was not more effective than placebo. So that's an example of a result actually suggesting that medication is working rather well in some studies. So I think a real message for practitioners is that we don't want to throw the baby out with the bath water in terms of potentially losing a useful therapeutic intervention in young people with significant depression.Ìý
PORTER
Do you think that the problem with SSRIs in younger people highlights a problem with the medication or do you think it is that we're finally coming to understand that possibly depression in children is different from depression in adults?Ìý
HAYMAN
That's a very good question because I think one of the mysterious things about depression in young people is, for example, it doesn't seem to respond at all well to the older generation of antidepressants - the tricyclic antidepressants - which does suggest it's a somewhat different entity. But again there has been a very interesting study just published looking in fact at the UK GP prescribing of antidepressants and suicide rates and suicidal behaviours and has shown that if you treat adults and young people with antidepressants of any group, so the older tricyclics and the SSRIs, you do see an increase in suicidal behaviour after the first nine weeks of beginning treatment. It could be something about the fact that people start taking antidepressants when they're at their most depressed - that's when they go to see a doctor and say look I really need some help now - and so it's not coincidence that they're at their most desperate or their most suicidal at around that time. And we also have some suggestion that just as people begin to recover from depression they may be more likely to have suicide attempts or behaviours - they've got more energy, more activation to act on those very miserable thoughts than they did when they were more profoundly depressed. And whether this process is really different in children or not I think we still don't know. But in that huge sample I think what is very interesting - it was a large sample, 10,000 people in the UK collected over a five year period - there were 15 completed suicides in under 18 year olds but actually none of those were taking antidepressants. So if anything there's some suggestion that the depressed young people on antidepressants were somewhat protected from suicide.Ìý
PORTER
So what are we going to do in the future to make sure that we can learn more about the effectiveness of the products and how to use them in younger people?Ìý
HAYMAN
Well I think we do need more studies. I know it sounds a repetitive thing to be saying but I think until carefully designed and carried out studies are done in young people we really don't have the answer because the studies that do exist actually get interpreted rather differently, there's been a review article published recently by somebody who looked at the reviewed - the published papers on the SSRI use in children and also compared the UK drug regulatory authority's policy with the US policy and found that all of these agencies had actually interpreted both the efficacy - how well these drugs worked in children - and the suicide behaviour risk rather differently. So I think that goes to show that even the information we have can be interpreted differently. So I think things like the very good study that has just come out, really using large numbers of children, comparing psychological and medical treatments, and also looking at what happens to children when you don't treat them at all - coming back to your question about are children different - we do have some suggestion that children recover naturally from depressed episodes - all of these things need more investigation.Ìý
PORTER
Dr Isobel Hayman.Ìý
Tim, you think the studies have been done, they just haven't been published because they don't show the right results.Ìý
KENDALL
No indeed, I think that's - indeed we showed this in a paper in the Lancet, published in April, in which we very fortunately had access to all the unpublished as well as the published studies for the treatment of depression in children using SSRIs. And when we looked at the published studies only our conclusion was that it was likely that they were effective and that they were safe. And when we then combined those with all the unpublished stuff it looked like they were ineffective and unsafe. So we at the end of this became quite sceptical about claims of efficacy and safety.Ìý
PORTER
Because they're cherry picking the studies then.Ìý
KENDALL
They're cherry picking absolutely, I think the drug companies, quite understandably, I mean that's the nature of what it is to be a drug company, they're cherry picking the studies that they believe show effectiveness and safety for their drug and not publishing the ones that don't.Ìý
PORTER
Do you think we could improve the management of depression in children then?Ìý
KENDALL
Well I think the first thing is that we could have access to all the research that's out there so that we can come to a proper judgement based on - and this is something that is happening, GlaxoSmithKline have agreed to publish all of their unpublished trials, so that's step one. Step two, I think is to look at funding research that will examine psychological, social as well as pharmacological methods of helping. Now if we look at adults quite a lot of result is out there of one kind or another looking at a range of different interventions, some of which are pharmacological, some of which are psychological or social, we don't have that much data about children. It does appear that children generally have been seriously under-researched.Ìý
PORTER
All of these studies compare treatments, whether they be CBT or a drug to placebo but of course placebo itself, although we might not be giving a patient an active treatment, we are talking and supporting them, it's quite effective in treating depression isn't it - just placebo.Ìý
KENDALL
It's very effective and it's a shame that it's called placebo - I wish we had a different word for it, perhaps a phrase such as extremely good clinical care in which the patient genuinely feels that you're interested in what's going to happen to them and that they're going to see you again and that you're going to be there whilst you support them through the treatment. So that whatever treatment you're giving them in terms of a pill, or even in terms of a psychological treatment, there is an undercurrent that you are there for them, that you're supporting them and that I think is what happens with placebo.Ìý
PORTER
Well recovering from depression is hard enough if the rest of your life is in perfect order - but what happens when it isn't? The leading housing charity Shelter are all too aware of the link between homelessness and mental health problems - but does depression lead to homelessness, or does homelessness increase the risk of depression. We sent Trisha Macnair to investigate. Adam Sampson is Shelter's director.Ìý
SAMPSON
Increasingly in Shelter we're seeing significant evidence that it is the housing conditions in which they're having to live that cause the problems. A recent survey we did of families in emergency temporary accommodation indicated that over three quarters of the people said they had a specific health problem which resulted from their housing position and over half of those people in emergency accommodation were actually suffering from depression.Ìý
MACNAIR
A breakdown in her relationship and problems with domestic violence left Sharon Bullock and her children homeless. They took shelter in a refuge before being housed for several weeks in bed and breakfasts and then a year in a flat in a homeless unit. Coping with two small children in temporary accommodation proved extremely difficult.Ìý
BULLOCK
It was very, very stressful, not knowing really from one day to the next where you were going to be placed. So it was insecure. I got very down, in the temporary accommodation we were in there were a lot of restrictions - it was security guarded 24 hours, you weren't allowed to stay out more than two nights, you were not allowed visitors after 10 at night. So you couldn't have maintained any kind of relationship there. Nowhere for the children to play, that kind of thing, it was very isolating.Ìý
SAMPSON
The reasons why people may be depressed because of their homelessness are manifold. First of all there's the physical conditions in which they live, very often the emergency accommodation, the temporary accommodation, is simply not fit for use - overcrowding, inadequate access to hygiene or to cooking. And those things are obviously going to have an impact. Secondly, there is this sense of hopelessness, you may be in and out of accommodation for years and you're not even staying in the same place, you're moved on a very regular basis. You're unable to work because of the very high rents that you have to pay which can only be met out of housing benefit. Finally, there's a real problem in getting access to support, they don't have access to their normal doctors, the kids don't get access to their normal schools, their friends, their support mechanisms, all of those have been taken away from them.Ìý
MACNAIR
It's not surprising that adults often become depressed while trying to cope with this sort of situation but it's the long term effects on children which particularly concerns Adam Sampson of Shelter.Ìý
SAMPSON
With children what is particularly concerning is that there's an increasing amount of evidence to indicate that the psychological problems that are caused by homelessness as a child recur in adult life. Now there's a lot of evidence from our surveys that children in particular suffer greatly from depression because of homelessness, about two thirds of the respondents to our survey indicated that their children had problems at school and nearly half described their children as often unhappy or depressed.Ìý
BULLOCK
It's certainly affected my daughter, yes, she couldn't understand why we were living there and why all her friends - they have gardens and things - and we couldn't do the things that they could do. Her behaviour changed substantially. She wrote on the fridge magnets - I hate you mum. Any pictures that she drew were sad faces, well it was just awful really.Ìý
MACNAIR
Sharon managed to get some help with family therapy but it wasn't provided as often as she felt she needed it.Ìý
BULLOCK
They would ask, you know, what problems I had, what's going on at the moment, what's upsetting you and if Ellie was behaving in a particular way asked me how I dealt with it, gave me suggestions of how better to deal with it and really just point out that it is normal when I was doing remarkably well to be coping with it. I think when you're isolated like that and when you are depressed you think you're some kind of loony. I had tried antidepressants but I just felt a lot worse with them, so I stopped those. I've a new home now and things are better but there are still things that play on your mind, things that still make me angry because they weren't sorted correctly and I think if someone else wasn't as strong minded as I was and didn't fight as hard as I did then I don't think they'd be here now, it does get you very, very depressed and suicidal.Ìý
PORTER
Sharon Bullock talking to Trisha Macnair.Ìý
Tim, I know you're in the middle of drawing up some national guidelines for depression, for the treatment of depression. Now I know you're not going to give us a sneak preview, but what sort of general flavour can we expect?Ìý
KENDALL
I think that what we should be doing is we should be solidly engaging our patients, listening to them, caring for them and in that context that we should be laying out a stall in front of them that includes guided self help, problem solving treatments, exercise, CBT, drug treatments and we should be saying to them - What suits you?Ìý
PORTER
So you think that any intervention is good and we should be trying harder to match it to the patient?Ìý
KENDALL
Absolutely, if you do nothing, things do not improve but if you do something, and you do one of the ones I'm suggesting, if it suits the patient, they will do well.Ìý
PORTER
Dr Tim Kendall, thank you very much. That's it for this weekÌý
Don't forget you can listen to the programme again by clicking on to the website at bbc.co.uk/radio4.Ìý
Next week's programme is all about contraception - how close are we to the male pill? Will men want to take it and, if they do, can they be trusted?Ìý
ENDS
Ìý
|
ÌýPrint this page
