University of Wollongong Research Online University of Wollongong Thesis Collection University of Wollongong Thesis Collections 2012 Depression and antidepressants in Australia and beyond - a critical public health analysis Melissa Raven University of Wollongong Recommended Citation Raven, Melissa, Depression and antidepressants in Australia and beyond - a critical public health analysis, Doctor of Philosophy thesis, Faculty of Arts, University of Wollongong, 2012. http://ro.uow.edu.au/theses/3686 Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library: [email protected] Depression and antidepressants in Australia and beyond A critical public health analysis A thesis submitted in fulfilment of the requirements for the award of the degree Doctor of Philosophy from UNIVERSITY OF WOLLONGONG by Melissa Raven BA(Hons), MPsych(Clin), MMedSci(ClinEpid) Faculty of Arts 2012 ii Certification I, Melissa Raven, declare that this thesis, submitted in fulfilment of the requirements for the award of Doctor of Philosophy, in the Faculty of Arts, University of Wollongong, is wholly my own work unless otherwise referenced or acknowledged. The document has not been submitted for qualifications at any other academic institution. Melissa Raven 5 July 2012 iii iv Concise table of contents List of acronyms .................................................................................... xiii Abstract ................................................................................................... xv Publications in support of thesis ........................................................... xvii Acknowledgments ................................................................................. xix 1. Introduction ......................................................................................… 1 2. Background: Depression and antidepressants ................................... 39 3. Players in the depression/antidepressant arena .................................. 73 4. Current debates about depression .................................................... 109 5. Current debates about suicide .......................................................... 139 6. Current debates about antidepressants ............................................. 159 7. Pharmaceutical industry practices and issues .................................. 245 8. Depression awareness campaigns: Selling depression and antidepressants ................................................................................ 339 9. The Mental Health Foundation of Australia's National Depression Awareness Campaign: Selling depression and antidepressants ..... 379 10. Conclusion ..................................................................................... 425 Appendices ........................................................................................... 435 References ............................................................................................ 442 v Detailed table of chapter contents 1. INTRODUCTION 1.1 INTRODUCTION ............................................................................................. 1 1.2 DISCIPLINES AND PERSPECTIVES ........................................................… 4 1.3 DEPRESSION ...............................................................................................… 9 1.4 ANTIDEPRESSANTS .................................................................................... 11 1.5 SIGNIFICANCE OF THE ISSUE .................................................................. 13 1.5.1 Large numbers of people receiving depression diagnoses/treatment ... 14 1.5.2 Problems with diagnosis of depression ................................................. 15 1.5.3 Problematic epidemiology of depression .............................................. 16 1.5.4 Inappropriate generalisation of evidence about depression .................. 16 1.5.5 Under-researched outcomes for untreated depression .......................... 17 1.5.6 Questionable theories of depression and antidepressant action ............ 17 1.5.7 Medicalisation of personal and social problems ................................... 18 1.5.8 Under-researched social causes of depression ...................................... 18 1.5.9 Overstated effectiveness of antidepressants .......................................... 18 1.5.10 Overstated safety of antidepressants ................................................... 20 1.5.11 Public beliefs that antidepressants are problematic ............................ 21 1.5.12 Antidepressant prescription outside diagnostic criteria ...................... 21 1.5.13 Substantial and increasing costs of antidepressants ............................ 22 1.5.14 Aggressive enlargement of the market for antidepressants ................ 22 1.5.15 Under-research and under-funding of alternative treatments ............. 23 1.6 METHODOLOGY .......................................................................................... 24 1.6.1 Critical analysis of claims ..................................................................... 24 1.6.2 Analysis of strategies of advocates ....................................................... 31 1.7 CONCLUSION ............................................................................................... 37 2. BACKGROUND: DEPRESSION AND ANTIDEPRESSANTS 2.1 INTRODUCTION ........................................................................................... 39 2.2 DEPRESSION ................................................................................................. 40 2.2.1 History of depression ............................................................................ 40 2.2.2 Experiences of depression ..................................................................... 42 2.2.3 Happiness .............................................................................................. 45 2.2.4 Depression diagnosis ............................................................................ 45 2.2.5 Epidemiology of depression ................................................................. 48 2.2.6 Causal factors ........................................................................................ 50 2.2.7 Treatment .............................................................................................. 51 2.3 ANTIDEPRESSANTS .................................................................................... 52 2.3.1 Pharmacology of antidepressants .......................................................... 55 2.3.2 Antidepressant epidemiology ................................................................ 59 2.3.3 Reasons for antidepressant prescribing ................................................. 63 vi 2.3.4 Likelihood of antidepressant prescription after depression diagnosis .. 65 2.3.5 Duration of antidepressant use .............................................................. 66 2.3.6 Who uses antidepressants? .................................................................... 66 2.3.7 Antidepressant risks .............................................................................. 68 2.3.8 Effectiveness of antidepressants ........................................................... 70 2.3.9 Economics of antidepressants ............................................................... 71 2.4 CONCLUSION ............................................................................................... 71 3. PLAYERS IN THE DEPRESSION/ANTIDEPRESSANT ARENA 3.1 INTRODUCTION ........................................................................................... 73 3.2 CONSUMERS ................................................................................................ 75 3.3 HEALTH PROFESSIONALS AND PROFESSIONAL ORGANISATIONS ..........................................................................................................................77 3,3.1 Doctors .................................................................................................. 77 3.3.2 Medical professional organisations ....................................................... 81 3.3.3 Psychologists and other therapists/counsellors ..................................... 83 3.3.4 Pharmacists ........................................................................................... 83 3.3.5 Nurses ................................................................................................... 84 3.3.6 Researchers and academics ................................................................... 84 3.4 THE PHARMACEUTICAL INDUSTRY ...................................................... 85 3.5 GOVERNMENTS ........................................................................................... 86 3.5.1 US governments .................................................................................... 87 3.5.2 Australian governments ........................................................................ 89 3.6 WORLD HEALTH ORGANIZATION .......................................................... 97 3.7. MEDICAL JOURNALS ................................................................................ 98 3.8. LAWYERS ..................................................................................................... 99 3.9 CONSUMER GROUPS AND COMMUNITY ORGANISATIONS ........... 100 3.10 OTHER ORGANISATIONS ...................................................................... 101 3.10.3 Cochrane Centre