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It’s doing your head in: the hidden mental toll of all those crises.

We live in a time of anguish: interest rates, cost of living, rents, mortgages, healthcare, the pandemic, the GFC, job insecurity, climate change. It’s having its consequences.

Over the past 25 years, rates of anxiety and depression have soared – by 29% for depression and by 77% for anxiety, according to surveys by the Australian Bureau of Statistic. By now, around 3.4 million people experience clinically significant anxiety-related conditions in a single year. For depressive illnesses, it’s 1.5 million.

These are the disorders of fear and of loss. They can be debilitating and sometimes life-threatening. And they are part of living the way we do now.

Anxiety and its burden

The term “anxiety” conjures an image of minor stress. But it’s much more than that. Six disorders grouped under the anxiety label:

Panic Disorder can involve sudden and repeated panic attacks of overwhelming anxiety and fear, a feeling of being out of control, or a fear of death or impending doom.

Agoraphobia is a fear of leaving environments known or considered to be safe. In severe cases, a person with agoraphobia considers their home to be the only safe environment. They may avoid leaving their home for days, months or even years.

Social Phobia is much more serious than normal shyness. People who have social phobia experience extreme and persistent anxiety associated with social or performance situations. It can have significant physical symptoms, such as trembling, accelerated heart rate, nausea, faintness and an overwhelming urge to flee the situation.

Generalised Anxiety Disorder is worrying taken to an extreme and pathological degree. Worries associated with GAD are distressing, last a long time and may appear for no apparent reason. GAD is characterised by a feeling of apprehension and constant irrational worrying about potential threats to the person and their loved ones.

Obsessive-Compulsive Disorder is a long-lasting condition in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviours (compulsions), or both. People with OCD have time-consuming symptoms that can cause significant distress or interfere with daily life.

Post-Traumatic Stress Disorder may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. It can be emotionally or physically harmful or even life-threatening. PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue” after World War II, but PTSD does not just happen to combat veterans. It can occur in all people, of any ethnicity, nationality or culture, and at any age.

This graph shows what has happened to the prevalence of these disorders over the past quarter-century:

Disproportionate levels of anxiety-related conditions are borne by women.

That translates into the burden of disease – the impact of living with illness and injury and dying prematurely. One principal measure is the number of years lived with a disability. Australian women account for around 60% of all anxiety disease burden.

Depressive illness and its burden

Depressive, or affective, disorders include:

Depressive Episode is a state lasting for two weeks or more, in which a dark mood is all-consuming and one loses interest in activities, even ones that are usually pleasurable.  Symptoms of this type of depression include trouble sleeping, changes in appetite or weight, loss of energy, and feeling worthless. Thoughts of death or suicide may occur. Colloquially, this type of depression has often been known as a nervous breakdown.

Dysthymia is chronic low mood that has lasted for at least two years but may not reach the intensity of major depression. Many people with this type of depression are able to function day to day, but feel low or joyless much of the time.

Bipolar Affective Disorder, once known as manic depression, involves wild swings between deep, crippling depression and exalted periods of mania: grandiose ideas, unrealistically high self-esteem, decreased need for sleep, thoughts and activity at higher speed, and ramped-up pursuit of pleasure including sex sprees, overspending, and risk taking.

Those rates have also increased but by much less than the anxiety conditions. It’s a fairly clear illustration of a close relationship between anxiety and troublesome life events. Affective disorders are more likely to be the result of a factor inherent to the person, such as genetic predisposition and personality. Both classes of disorder, though, are sensitive to serious life events.

As with anxiety conditions, the disease burden of depressive illness is disproportionately borne by women.

The validity and clinical usefulness of all of these classifications are being challenged by many practicing psychiatrists. Methods designed to understand physical illness don’t work, they say, for mental illness. For now, though, they remain the conventional way of looking at, and tracking, a distressing set of conditions.

Where? Who?

There’s nothing fair about mental illness. Some groups – the young, for instance – are far more likely to be affected than older people. Almost a third of people in the youngest adult age group, 16 to 24, have experienced clinically significant anxiety-related mental illness in the previous 12 months. And one in seven have experienced a depression-related disorder.

From there, the risk declines. The older you are, the less likely you are to be affected.

Sexual orientation is closely associated with risk. People who are gay, lesbian or bisexual are much more likely than heterosexual people to suffer these conditions: more than twice as likely for homosexual men and women, and over four times as likely if they’re bisexual.

Distribution between Australian jurisdictions is less pronounced but still significant. Overall, Tasmania has the greatest problems: the second-highest rate of anxiety and the highest rate of depression. South Australia is at the other end of the scale.

Employment is a major factor. People with a job are at much lower risk than the unemployed.

It’s perhaps not surprising that single parents, struggling to bring up children, to earn a living and to pay the rent have the highest levels of pathological anxiety. People in share homes are close behind.

There are striking correlations between overall mental illness and whether someone smokes or is experiencing chronic pain.

Rather unexpectedly, income seems to have only a slight correlation with anxiety and depression. These differences are too small to be of much statistical significance. Perhaps it’s true that money can’t buy happiness – or, at least, avert unhappiness.

Just take a pill! (Spoiler: it’s not that simple)

Although drugs are available for treating anxiety conditions, their use can be problematic. There are two broad categories – anxiolytics and antidepressants.

Anxiolytic (anti-anxiety) drugs tend to be addictive. These include the benzodiazepines (such as Valium). They can be useful in the very short term to stabilise extreme symptoms but, beyond that, are not the answer to most people’s problems.

Probably for that reason, the use of these drugs has been declining sharply. Nevertheless, more than three per cent of the Australian population are prescribed them annually.

Prescription patterns are sharply at variance with the age distribution of symptomatic illness. An earlier chart in this post showed how prevalence declines with age: according to the Bureau of Statistics study, about a third of people between 16 and 24 report anxiety of clinical significance. That rate declines steadily, with a rate of less than four per cent among those between 75 and 85.

Patterns of prescribing, though, go in the opposite direction.

Most treatment options for pathological anxiety involve non-drug interventions, such as cognitive behaviour therapy. CBT usually involves efforts to change harmful thinking patterns and is backed by a large body of scientifically rigorous studies.

Antidepressants are also used in anxiety treatment for some patients, as well as for treating depressive illness.

Most antidepressant prescriptions are for a single class of drugs, the selective serotonin reuptake inhibitors. The most popular, sertraline (brand name Zoloft) is the 14th most often-prescribed drug on the Pharmaceutical Benefits Scheme.

In contrast to the trajectory for anxiety drugs, antidepressant prescribing continues to boom, as it has for decades. And a noticeable increase in the trend coincided with the pandemic from 2019-20.

Again, though, patterns of prescribing are at variance with the age distribution of disease. As an earlier chart showed, people in their teens and early twenties are most likely to be depressed. The risk then declines evenly through life. But these drugs are given mostly to people in mid-life.

This can be partly explained by the reluctance to prescribe these problematic medications for young people. Side-effects include the suppression of libido and erectile dysfunction; and some SSRIs can induce suicidal thoughts and behaviour in adolescents.

Nevertheless, the relative decoupling of prescribing from illness is a matter of potential concern.

Of the 29 countries for which comparative data are available, Australia’s rate of antidepressant consumption ranks as third. That’s double the 29-nation average. Even in countries with far lower levels of prescribing, there have been concerns about significant and continuing increases in antidepressant use despite little evidence of any similar increase in the prevalence of disease.

Here’s a clue about what might be happening. As this chart shows, the vast majority of prescriptions for antidepressants and for anxiolytics are written by general practitioners.

Treatment of psychiatric disorders is often nuanced and complex. But the Medicare system, designed as it is for dealing with physical disorders, is ill-equipped to provide nuance or to deal with complexity. It is not possible, within a 15-minute consultation, to fully and appropriately deal with many of these patients. Prescribing a drug is often the only practical course for a busy GP, even though this is often not the best treatment and may cause more harm than good.

Drug prescriptions are an imperfect measure of actual illness. There are many possible factors at play here, and doctors are far from immune to the prevailing culture among nearby colleagues. There are fashions in medical practice, and this looks like one of them.

Why, for instance, should Adelaide City have the highest rate of mental health drug prescribing of anywhere in Australia?

The Australian medical system is dealing poorly with the treatment of people with mental illness. When antidepressants are used wisely in people with major depressive illness –  generally in combination with non-drug interventions – they can be life-changing and life-saving. But these drugs, as well as addictive benzodiazepines, are being prescribed to people with mild to moderate depression and anxiety. That is seldom the best way to treat them.

“Most antidepressants are prescribed by primary-care physicians who may have limited training in treating mental health disorders,” said an article published by the American Psychological Association in its journal, Monitor on Psychology.

“After reviewing the published literature, the National Health Service in England adopted cognitive behavioural therapy as a first-line treatment for mild and moderate depression because the risk-benefit ratio is poor for antidepressants.”

The journal quoted Dr Steven Paul, a neuroscientist at Weill Cornell Medical College in New York: “Several studies and his own clinical experience as a psychiatrist showed that a combination of antidepressants and cognitive behavioural therapy were the most effective method for treating depression. 'Medication treatment is but one way to treat depression,' he says. 'It's not necessarily the best way or the only way.'”

But it’s what the system allows. Perhaps the system needs to change.

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