Treating depression: a new approach
One in five Australians is living with depression. Online therapy is emerging as an effective and accessible treatment option.
Health Agenda magazine
Mental illness is a largely silent problem, but the cost in health terms shouts loud enough: $200 billion a year – the equivalent of about 12 per cent of the Australian economy’s annual output.
Understanding the underlying causes of these costs is simple: one in five Australians suffers from depression, but 75 per cent do not seek treatment. The reasons are as varied as they are manifold: long-term unemployment or social isolation, a family history of depression, illness, drug and alcohol abuse – even personality type.
The list of typical symptoms is also long: alongside a depressed mood are irritability, changes in appetite, weight and sleep, reduced concentration, decreased pleasure and in some cases suicidal thoughts.
For people who do seek treatment, therapy varies. “There are, generally, two treatments that work for depression,” explains psychiatrist Professor Gavin Andrews of St Vincent’s Hospital in Sydney, “medications, like Prozac or Sertraline, and cognitive behaviour therapy (CBT) with a clinical psychologist.
Antidepressant use has increased all over the world since the 1980s. This prevalence is linked with the development 20 years ago of a new class of selective serotonin reuptake-inhibitors (SSRIs) – Prozac is the most recognised – with far fewer side effects than earlier antidepressant drugs.
Since then antidepressant prescriptions have multiplied roughly sixfold in this country. An independent study conducted by researchers at the University of Sydney’s School of Psychology reported a 95.3 per cent leap since 2000. It seems before the advent of SSRIs depression was under-treated, but now many experts argue that SSRIs are being over-prescribed.
An article published in the Journal of the American Medical Association presented research that antidepressants are no more effective than placebos for patients, except for the very severely depressed.
The non-drug option
Alongside these developments in drug research, clinicians have continued to prescribe CBT, which encourages patients to examine and change their behaviour. “Medication was the original treatment for depression,” says Professor Andrews.
“There is now strong evidence that CBT can be as effective for mild to severe depression and it has no side effects.” Of course, any changes to taking prescribed medication should always be managed by a doctor.
“In CBT, the therapist will analyse how mood regulation has gone wrong in this patient, identifying just how habitual thoughts, behaviours and emotions prepare the person to be overly depressed or anxious,” he explains.
“CBT teaches the person to challenge the worrying or self-defeating thoughts, to enter and master the defeating situations and to limit the degree that depression or anxiety is felt.”
A 2015 report by the Australian Institute of Professional Counsellors (AIPC) confirms CBT’s efficacy as a treatment for depression, even citing consolidated data from further studies showing a threefold preference for psychological treatment over medication.
At the other end of the spectrum is electroconvulsive therapy (ECT), a procedure used to treat depression resistant to gentler forms of treatment. It involves passing a carefully controlled electric current through the brain, disrupting the brain’s activity and relieving severe depressive or even psychotic symptoms.
Far from the horror movie practices of old, modern-day ECT is still only considered when the situation is thought to be life threatening or after all other treatment options have failed. The main side effect is memory loss, which usually resolves after a few weeks but can last longer. For some the benefits outweigh the side effects; others can find the loss of memories very distressing.
When treatments don’t work
Quantifying the efficacy of treatments is difficult. Some patients stop medication due to side effects or because they don’t believe it’s working; other CBT subjects may cease attending appointments because the financial and time sacrifices are too great.
Another factor is human resources. Professor Andrews and his team at St Vincent’s Hospital have seen waiting times for CBT patients increase exponentially, with some people having to wait up to six months to begin their treatment. For someone living with depression, six months can feel like an eternity.
Professor Andrews notes this is obviously not ideal. “Unfortunately many people with depressive disorders just soldier on, stoically making the best of it, accepting that life has to be lived at half pace.”
Making therapy more accessible
Ultimately, the goal is to make CBT accessible to everyone, a goal most achievable through digital and independently guided self-help means.
“In therapy the remedial strategies are discussed and an individual plan is made for each person,” Professor Andrews says, “but in most people who are too sad or too worried, the thoughts, behaviours and emotions are very much the same, and so it has been possible to identify these commonalities and design the elements of a therapy that applies to all.
“Once this information is specified it can be computerised, and because of this it can be taught and learned and remembered and put into practice so that people regain control over their negative thoughts, behaviours and emotions.”
In a bid to boost mental health therapy across the country, part of the Federal Government’s action plan is the creation of a new digital gateway. Professor Andrews says Australian universities lead the world in the development of such courses, and he and colleague Nick Titov from the University of New South Wales have developed a Virtual Clinic program to be ‘prescribed’ for depression.
This way up
St Vincent’s Hospital also offers a number of online courses, in its This Way Up program, which covers depression and associated mental health issues. Regular sessions are scheduled with participants, together with mental exercises to practise between visits.
Courses last up to three months and on completion participants are granted an extra 90 days access for practising their newly learned cognitive behaviours. It’s an innovative alternative to face-to-face therapy.
Independent reviews show that 80 per cent of people who complete one of these courses improve, 50 per cent to the point of no longer having difficulty with depression.
Online CBT shows every sign of providing a viable solution to meet the need for treatment as well as potentially reducing the prescription of medications.