Depression: reducing the burden

Depression is now Australia’s most debilitating illness, accounting for 8% of all years lived with disability and over $3 billion annually in direct and indirect costs. 1 Other mood disorders, such as bipolar disorder, add significant additional costs. 2 Unfortunately, mood and anxiety disorders, which typically first become evident in adolescence, often go untreated or only come to attention later in adult life. Thus, people who present for care have recurrent or persistent disorders. 3 Moreover, depressive disorders are frequently complicated by alcohol or other substance misuse,4 as well as physical health problems. 5 Mental disorders in total now account for 60% of all disability costs in those aged 15–34 years. 1 In a caring society, such statistics should demand an urgent, national and coordinated response. One aspect of our national response was the establishment in 2000 of beyondblue: the national depression initiative by the Australian and Victorian governments. 6 Towards the end of its first phase (2001–2005), it is now time to assess our progress. To reduce the burden of depression, we need an effective combination of prevention and early intervention; expanded evidence-based treatments (particularly in primary care); a reduction of social and economic barriers to full participation, such as exclusion from life insurance or discrimination in the workplace; and promotion of research on related health services and suicide prevention. 7 Early achievements of beyondblue: the national depression initiative 27% of Australians in 2002 recognised “beyondblue” as the national depression initiative. 61% of Australians in 2002 reported that they or someone close to them had experienced depression. beyondblue generated 1762 unique media stories between 1 April 2001 and 30 June 2004. The beyondblue website recorded 644 999 visits between 1 April 2001 and 30 June 2004. Support for critical changes in primary mental healthcare, introduced under the $120 million Better Outcomes in Mental Health Care package. Establishment of blueVoices as a new national consumer and carer advocacy network. Production of new guidelines with the life insurance and income protection industries to ensure equitable access for people with depression. Support for large national trials of primary and secondary schools-based, antenatal and community depression prevention and early intervention strategies. 8-10 Support for health services research through allocation of large research grants, focusing on the interface of primary and secondary care. In this Supplement, evidence is presented either directly from beyondblue or from analyses of other available national data sets. Importantly, the early impact of beyondblue can be seen in impressive rates of national awareness of the organisation, the number of media contacts, the extent of website utilisation, changing social attitudes to reporting personal experiences of depression, and reduced barriers in access to life insurance and income protection (see Box). 7 However, the personal experiences of those who care for people with depression,11 and the treatment experiences of those with bipolar disorder,12 indicate that there is still a great deal of work to be done to reduce stigma and to improve the interaction with healthcare services of people with severe affective disorders. A novel method for drawing media attention to our national progress, or our progress within target groups of greatest concern (eg, young people, new mothers, Indigenous Australians, small rural communities), is the development of a National Index for Depression. 13 We intend to report this index frequently, so that the general public and the media become as familiar with it as they are with other national measures like the road toll or the annual suicide rate. Prioritisation of mental health within Australian general practice is critical. beyondblue played a key role in advocacy for the $120 million national program Better Outcomes in Mental Health Care (BOiMHC) 2001–2004. 14 Others have highlighted the cost-effective health outcomes that could be gained by this type of reform, in that it seeks a better balance of primary and secondary care as well as improved access to specific cognitive-behaviour strategies. 15 The initial impact of BOiMHC is apparent, with 15% of the general practice workforce now participating. 16 If the program continues to promote improved consumer and carer choices and better access to non-pharmacological treatments, then the goals of higher remission rates, prevention of recurrence and delivery of cost-effective treatments may be achieved. Accompanying the rapid expansion in management of depressive disorders in primary care is the inevitable rise in the level of prescribing of antidepressant medications. Although this increase is associated with clear benefits, most notably a decline in suicide rates in those who access care,17 the wider community has been quick to question whether this increase is appropriate. 18,19 Mant et al have examined the trends in general practice prescribing and conclude that there is evidence of appropriate restraint in the use of these new antidepressants. 20 Another aspect of primary care management of depression is the common link to life-threatening substance misuse. Burns et al explore what we know about the links between mental health, prescription drug use and heroin overdose. 21 The number of Pharmaceutical Benefits Scheme prescriptions provided has a very strong relationship with overdose, particularly for benzodiazepines, opioids, and tricyclics, but not for the newer antidepressant agents. Self-care strategies for depression and anxiety are an increasingly important part of the mix of treatments that need to be available to the wider community. Previously, Jorm et al detailed the evidence for such strategies for treating depression. 22 Here, they set out the current state of knowledge of self-care strategies for anxiety disorders. 23 Anxiety disorders are often either the precursor to depression or a major source of comorbidity. Although a great deal of concern is expressed about rates of mental disorders in rural and regional Australia, very few systematic data have been available for detailed analysis. Caldwell et al report a most important finding — that an underlying factor relating to increased suicide in young men in rural and regional settings is lower use of services rather than higher rates of mental disorder. 24 This now requires an urgent suicide prevention and health services response. To date, few countries in the developed world have attempted such a coordinated population health response to the burden of depression. The most recent British initiative achieved limited benefits. 25 Improvements of 5%–10% were reported in terms of more positive attitudes to depression, reported experiences of depression, attitudes to antidepressants and treatment from GPs. 25 Few GPs (11%) had definitely made changes in their management of depression as a result of the campaign. 26 At this early stage, the Australian experience appears to be achieving wider benefits and establishing a broader framework for more sustainable changes in community attitudes and health service reform.

Ian B Hickie MD, FRANZCP

Objective: To explore the experiences of carers and families of people with depression.Design and setting: Structured focus groups conducted in six Australian capital cities between February 2002 and July 2002. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Thirty-seven carers or family members.Results: Thematic analyses highlighted five key themes. Most notably, the carer’s role is made more difficult by the lack of community awareness about depression, and, in some instances, an unwillingness of other family and friends to provide ongoing support. Carers experience a resulting sense of isolation, often exacerbated by adverse experiences with healthcare providers. Carers and family members are frequently excluded when key decisions are made, and report that emergency services are relatively unresponsive to their concerns. By contrast, community support organisations usually provided a sense of inclusion and common purpose.Conclusions: The experiences of carers and families of people with depression highlight the urgent need for more extensive community education about the illness and more productive collaboration within the healthcare system.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

Objectives: To compare the prevalence of mental health disorders and the use of professional help by area of residence, age and sex; and to determine whether the differences parallel differences in suicide rates.Design: Retrospective cross-sectional analysis of Australian national mortality data (1997–2000) and the National Survey of Mental Health and Wellbeing (1997), using broad area-of-residence classifications based on the Rural, Remote and Metropolitan Area (RRMA) index.Main outcome measures: (a) Suicide rates; (b) prevalence of depression, anxiety and substance-use disorders; and (c) use of health professionals for mental health problems — by age, sex and area of residence.Results: Higher suicide rates were evident for men, particularly young men in rural (40.4 per 100 000; z, 3.2) and remote (51.7 per 100 000; z, 7.2) populations compared with metropolitan (31.8 per 100 000) populations. Although the proportion of young men reporting mental health disorders did not differ significantly between rural (23.5%; z, –0.5) and remote (18.8%; z, –1.6) areas compared with metropolitan (25.6%) areas, young men with a mental health disorder from non-metropolitan areas were significantly less likely than those from metropolitan areas to seek professional help for a mental health disorder (11.4% v 25.2%; z, –2.2).Conclusions: There is a need to investigate why young men in non-metropolitan areas, the population with the greatest suicide risk, do and do not engage with mental health services.

Tanya M Caldwell PhD · Anthony F Jorm PhD, DSc · Keith B G Dear PhD

Objectives: To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support.Setting: All Australian states and territories during the first 15 months of the initiative (1 July 2002 – 30 September 2003).Design: Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from “access to allied health services” projects to the Australian Department of Health and Ageing (project participation).Main outcome measures: Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support.Results: Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine “access to allied health services” projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the “access to psychiatrist support” component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present.Conclusion: The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons), GCM · Jane E Pirkis PM(Psych), PhD · Grant A Blashki MD, FRACGP · Grace L Groom DHSc

Objective: To examine trends in types of antidepressant medications prescribed in Australia between 1975 and 2002.Design: Sales data from the Australian pharmaceutical industry were used to examine trends in overall antidepressant prescribing and changes in the types of antidepressants prescribed between 1975 and 2002.Main outcome measures: Antidepressant sales were expressed as defined daily doses (DDDs) per 1000 people per day, using the estimated Australian population for each year obtained from the Australian Bureau of Statistics.Results: Average annual growth in the sales of antidepressants was 1.1% per year from 1975 to 1990, after which growth rose steeply to reach 29% in 1995. By 2002 the rate of growth had slowed to 6.6%. Eighty per cent of total sales were accounted for by four drugs in 1975, 1980 and 1985; five in 1990; seven drugs in 1995 and 2000; and six drugs in 2001 and 2002.Conclusions: The rapid growth in antidepressant prescribing that was characteristic of the early 1990s, and reflected the emergence of new classes of agents, did not continue into the late 1990s. Selective serotonin reuptake inhibitors now dominate antidepressant prescribing in Australia.

Andrea Mant MD, MA, FRACGP · Valerie A Rendle BSc, MSc, MPsychClin · Wayne D Hall BSc(Hons), PhD · Philip B Mitchell MD, FRANZCP, FRCPsych · William S Montgomery BPharm · Peter R McManus MMedSc, BPharm · Ian B Hickie MD, FRANZCP

Objective: To identify patterns of mental health, prescription drug use and personal circumstances associated with heroin overdose in young people.Design: Linkage of data on use of Pharmaceutical Benefits Scheme (PBS) prescription drugs with data from a self-report questionnaire.Setting: Inner metropolitan Melbourne, Australia.Subjects: 163 young people, 15–30 years, using heroin.Main outcome measures: Personal circumstances, mental health (as measured by various scales), and PBS-listed prescription drug use.Results: Young people using heroin reported high rates of feelings of hopelessness, depression, antisocial behaviour, self-harm and diagnosed mental illness. A prior history of overdose was associated with previous mental illness, which in turn was associated with being female, having poor social support, being dissatisfied with relationships, and living alone or in temporary accommodation. While feelings of hopelessness and antisocial behaviour were strongly associated with overdose history, the number of PBS prescription drugs used had a very strong relationship with overdose, particularly benzodiazepines, other opioids, tricyclic antidepressants and tranquillisers.Conclusions: Further research to explore causal relationships between prescription drugs and heroin overdose is warranted. Improved data linkage to PBS records for general practitioners may facilitate safer prescribing practices.

Jane M Burns BA (Hons), PhD · Raymond F Martyres MB BS, MMed, FRACGP · Danielle Clode BA(Hons), DPhil(Oxon) · Jennifer M Boldero MA, PhD

Objectives: To review the evidence for the effectiveness of complementary and self-help treatments for anxiety disorders.Data sources: Systematic literature search using PubMed, PsycLit, and the Cochrane Library.Data synthesis: 108 treatments were identified and grouped under the categories of medicines and homoeopathic remedies, physical treatments, lifestyle, and dietary changes. We give a description of the 34 treatments (for which evidence was found in the literature searched), the rationale behind the treatments, a review of studies on effectiveness, and the level of evidence for the effectiveness studies.Conclusions: The treatments with the best evidence of effectiveness are kava (for generalised anxiety), exercise (for generalised anxiety), relaxation training (for generalised anxiety, panic disorder, dental phobia and test anxiety) and bibliotherapy (for specific phobias). There is more limited evidence to support the effectiveness of acupuncture, music, autogenic training and meditation for generalised anxiety; for inositol in the treatment of panic disorder and obsessive-compulsive disorder; and for alcohol avoidance by people with alcohol-use disorders to reduce a range of anxiety disorders.

Anthony F Jorm PhD, DSc · Helen Christensen PhD · Kathleen M Griffiths PhD · Ruth A Parslow PhD · Bryan Rodgers PhD · Kelly A Blewitt BAppPsych

Objective: To describe the experiences of people with bipolar disorder with primary care and specialist mental health services.Design and setting: Focus groups and indepth interviews were conducted in seven Australian capital cities between July 2002 and April 2003. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Forty-nine people with bipolar disorder participated in the focus groups and four participated in the interviews.Results: Thematic analyses highlighted eight key themes. Most notably, respondents identified a lack of awareness and understanding about bipolar disorder within the Australian community, which contributed to apparent delays in seeking medical assessment. The burden of illness was exacerbated by difficulties experienced with obtaining an accurate diagnosis and optimal treatment. The healthcare system responses were described as inadequate and included inappropriate crisis management, difficulties accessing hospital care, inappropriate exclusion of carers and families from management decisions, and frequent discontinuities of medical and psychological care.Conclusions: People with extensive experience of bipolar disorder report barriers to optimal care because of lack of community understanding and healthcare system shortcomings. These barriers exacerbate the social, interpersonal and economic costs of this illness.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Marie Thompson BSc(Hons) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

Objective: To develop a National Depression Index for measuring the depression status of the Australian population.Design: Cross-sectional data were analysed from two random samples of the Australian adult population — the National Survey of Mental Health and Wellbeing (2000) and the National Health Survey (2001).Participants: The National Survey of Mental Health and Wellbeing (2000) — 10 641 participants; and the National Health Survey (2001) — 17 918 participants.Main outcome measures: Selected items from the Kessler Psychological Distress Scale (K10); and diagnoses of a major depressive episode according to DSM-IV criteria using a computerised interview.Results: Six items from the K10 that were most closely related to the DSM-IV diagnosis of “major depressive episode” were identified. Scores on an index calculated from these items were rescaled to form an index reflecting relative risk of depression and having a value of 100 for the Australian adult population. Taking into account sex, employment status and income, index values were higher in younger people, females, unemployed people and those socioeconomically disadvantaged. This pattern provides additional support for the validity of the index, as well as establishing benchmark levels to which index values from future surveys and in other groups may be compared.Conclusions: The proposed National Depression Index is a valid indicator of depression and level of depressive symptoms. It is suitable for monitoring depression at the population level. The scaling characteristics of the measure ensure that it can be interpreted by members of the general public.

Andrew Mackinnon PhD · Anthony F Jorm PhD, DSc · Ian B Hickie MD, FRANZCP