In 1992, the ‘Defeat Depression’ campaign set out to educate GPs and the public about depression and the availability of treatment for it.1 In 2001, the follow-up ‘Changing Minds’ campaign urged doctors to be alert to the diagnosis of depression ‘at any age, even among children and young people’.2 Both campaigns were backed by the Royal Colleges of Psychiatrists and GPs, by the Department of Health — and by drug companies producing antidepressants.
It is not surprising that these campaigns have resulted in an upsurge in the diagnosis of depression among children as well as adults and that 40 000 under-18s are now taking antidepressants. Alarmed at this dramatic increase in the administration of psychotropic medication to young people — and at studies suggesting that some antidepressants may increase suicidal tendencies — the National Institute of Clinical Excellence (NICE) has now blown the whistle.3 Its latest report recommends that medication should not be offered at all to children with mild depression and only to those with more severe depression in combination with talking therapies.
The new guidelines, following an earlier edict against the prescription of all antidepressants except fluoxetine to under-18s, have been widely criticised on the grounds that the proposed talking cures (cognitive behavioural therapy [CBT], interpersonal therapy or family therapy) are in short supply. Although I am sceptical whether these therapies are any more effective than drugs, or indeed than no intervention at all, and wary of the dangers of long-term dependence on therapy, my main concern is about the expanding range of the diagnosis of depression.
A central theme of the recent NICE guidance — and of earlier campaigns — is the need for healthcare professionals to have further training ‘to detect symptoms of depression, and to assess children and young people who may be at risk of depression’. While some GPs might take offence at this slight on their capacity to make a familiar diagnosis, we must appreciate the need of psychiatrists to boost their fragile professional self-esteem by promoting the notion that they possess esoteric knowledge and skills that enable them to spot cases of depression that would pass unnoticed by the uninitiated.
But the real problem lies deeper. The aim of recent campaigns is not so much to encourage the diagnosis of depression in its traditional form as to promote the reinterpretation of a widening range of human experiences of sadness and loss — by doctors and patients, adults and children — in terms of mental illness. This is the significance of the promotion of claims that ‘one in four’ people suffer from depression (the estimated ‘lifetime prevalence’ headlined by the 2001 ‘Mind Out for Mental Health’ campaign). It is in this process of expanding the scope of psychiatric diagnosis that GPs and other health professionals are believed to require further training.
If psychiatrists are disparaging of GPs' diagnostic skills, they are even more dismissive of the capacities of ordinary people to recognise and cope with the exigencies of everyday life. The demand that children with difficulties should be directed into psychotherapy risks undermining the personal resources and informal networks that are crucial to children's psychological development and welfare. The drive towards professional intervention implicitly denies children's capacity to deal with their own difficulties, with the help of parents, family members and friends. Indeed, parents only figure in the NICE guidelines as potential objects of treatment in parallel with their children. Just as family relationships are widely perceived through the prism of abuse, so — whether the subject is bullying or teenage pregnancy — peer relationships are also pathologised. Yet when children experience bereavement or other traumas, they are more likely to benefit from the support of those closest to them than they are from any healthcare or psychological professional.
The key question is not whether fluoxetine or CBT is more effective for children. The key question is whether it is helpful to children or to society to label unhappiness as mental illness. In the legitimate quest to identify and treat appropriately a small number of cases of severe depression, we risk turning a generation of children into life-long clients of the therapeutic state.
- © British Journal of General Practice, 2005.
