Insightful article. I noticed the local GP prescribing antidepressants to my elderly mother - although her depression is clearly the result of her circumstances. (An entirely rational response it seems to me)

There are still far too many - pop a pill - treatments from doctors who are unwilling to take the time to see what the real problem is - and offer approaches to dealing with the circumstances.

It might be fairly argued that the problem "Richard" had was that he was in the all too common position of finding that neither his GP nor his psychiatrist talked to him. That kind of "talking", which concerns itself more with understanding distress in order to find solutions, rather than confining itself to technocratic issues of diagnosis and evidence based treatment has become less available. In my view, that in turn has a lot to do with medico-political issues that are generally not known about. For example, training in this type of "talking" (or intensive psychodynamic psychotherapy) has been downgraded in favour of short-term treatments like CBT; there's no problem with that until one meets a patient who needs the former and not the latter. Much of the policy difficulties, to simplify things, arguably arose when two things happened. The first is that the Howard Govt decided to restrict access to psychotherapy, thereby rationing treatment and promoting inequity there. The second is when "evidence-based treatment" came to be an issue which was less about scientific enquiry, and more about promoting inequity. Or, in other words, it came to be related to the issue of who decides what "evidence" is acceptable; that has a lot to do with politics rather than what a patient needs. A clinical problem has, arguably, become a mine-field because psychiatrists, GPs and patients have all been caught up in disempowering policies. The sad result is that examples like "Richard" are commonplace, as if it was ever thus. It wasn't.

I just wanted to weigh in from a patient’s perspective, and to add to a comment made in response to Part 1 of this series regarding insurance.

I identified very heavily with Richard* – for the most part I felt like the article could have been written about me. I had a very similar experience with my doctors except that I asked to be referred to a psychiatrist (one who had been recommended to me, at my request, by my brother’s psychiatrist). Yes, I had the family history as well, so I knew I had to be pro-active when it all started to become too much.

But that’s when things started to get really bad. I honestly walked out of my appointments with my psychiatrist feeling even more depressed than when I went in. I have a good capacity for self-analysis (in fact, part of my problem was that I over-analysed everything), and I went to my appointments prepared to discuss my progress each month as a result of that self-analysis. Unfortunately, all I got in return was – firstly a script for anti-depressants, and then later, a script for a higher dosage of anti-depressants.

I literally walked in the door and handed my psych a list of issues I was dealing with, what I was doing about them, and what I thought were the next steps for me to take. All I got in return was “here, take these, they’ll make you feel better”. Needless to say, I gave up on the psychiatrist after about 4 months (4 visits), I stopped taking the ADs, I rectified the issues that were causing me concern, and I haven’t looked back since.

Anti-depressants didn't work for me, because I wasn't just depressed, I was dealing with a whole host of medical and real world issues at the time. Of course, there were depressive elements to my condition, but once I had addressed the stressors, my condition improved rapidly. My psych kept trying to convince me that I was depressed, and that pills would help, without considering all the issues I was dealing with. And him continually telling me I was depressed made me feel even worse.

This brings me to my insurance problem. I had, prior to applying for my policy, taken myself off to see a psychologist when my husband and I were dealing with infertility. At the time, I thought nothing of it, I simply thought that I was being proactive in dealing with the grief that a diagnosis of infertility can bring. There is certainly no doubt that I was upset about it, and maybe I was depressed at the time, but neither my psychologist, nor my GP, ever did a Mental Health Plan with me, nor did either of them tell me that I was depressed, they simply suggested that a course of antidepressants would assist me.

I suppose in hindsight I was naive – perhaps them prescribing antidepressants should have been my hint that I had in fact been diagnosed with depression, but because neither of them said that, I simply thought that I had been through a difficult time, and worked my way through it with their assistance. I put it behind me and didn't really think on it again.

Given my profession, I should have known to declare it on my insurance application, and I am not complaining that my claim failed, because I accept personal responsibility – I should have known better. What I want to highlight though is that in denying my claim, my insurance company told me that if they had known my history, they would never have agreed to insure me (and they refunded all my premiums to prove it!).

My ‘history’ was simply that I had pro-actively sought treatment with a psychologist to deal with a discrete issue, and accepted a prescription for ADs without a Mental Health Plan being prepared or a diagnosis of depression being either made, or conveyed to me. For them, it was enough that the prescription had been made, and therefore I had a history of depression, and was uninsurable. The actual condition upon which I sought to claim on my insurance was not ‘depression’, and the only reason that depression came up at all in the claims process was because I had been proactive about my mental health and had taken myself off to see a psychiatrist at my own request.

I just want to share my story as a warning to others. Obviously, the first rule is to declare everything! But it also highlights the issues raised in this article, with GPs or psychiatrists simply writing prescriptions for anti-depressants without considering either the reasons for that ‘depression’ or whether that is the most effective treatment. And it’s a sad state of affairs for patients, but once you accept a prescription for anti-depressants, regardless of the reason, insurance companies will view you as having a history of depression and may refuse to insure you.

That rant out of the way, I was really interested to learn about the different types of depression. If I’d known that at the time I could have saved myself many an argument with the psychiatrist who kept insisting that I was depressed. I wish that he had explained to me that my depression was ‘reactive’ and would resolve once I had addressed the issues causing it (which I now know that it was, because it did). He didn’t, he just said ‘you’re depressed, here are some pills’ and so in my experience, the scenario described in this article is right on the money.

Speaking as a patient diagnosed with a mental illness and a full Disability Support Pension for the last ten years...

Cognitive Behavioural Therapy, medication, healthy food, exercise, family support and understanding, and social inclusion has eased my condition.

My main problem is I 'hear voices'.

The remaining piece of the puzzle is participating in policy design.

Most of the available information on mental health has been written
by mental health professionals, mental health charities, or researchers who are not patients.

Include people who have been labeled with a mental illness in policy design, and link processes with outcomes and the jigsaw puzzle should look better.

Achieving sensible sustainable policy goes wider than government action. Government can manage the end results of some policies, but not all. For
example, government can promote good health but people still smoke, eat junk food and become inactive. It can ban murder but people still kill.

Policy works best when it touches an emotional chord. It's a common strategy because we will only be receptive to the facts if we are already affectively committed to learning about the issue.

Setting time frames for decision making is important. But it still doesn't help
define what a sensible sustainable policy might look like... let alone motivate
people to take the decisions to move to a sensible sustainable policy.

Governments collectively and individually have a fundamentally important role in facilitating progress towards a sensible sustainable policy.

Governments need to show leadership... where they tread society will follow with a top down bottom up mixed economy approach.

A product, whether soap or industries, is more easily sold when an audience has affection for, or at least a predisposition toward that product.

There is positive opportunity where there is information overload and confusion. It's a matter of psyche... something as a patient I'm still coming to grips with in my recovery phase.

For example, look at the media. News must challenge the audience, with interlinked resources, attention, and content.

However, news channels don't have the resources to generate 24 hours of news each day. News watchers don't have the time or patience to watch 24 hours of news each day. And there isn't 24 hours worth of news content each day.

Each of those things pushes the most valuable feature of news toward "ease", opening a huge opportunity for industry advocates with detailed knowledge.

I have no doubt that this will be a worthwhile journey.

It needs to be done continuously, in each place, and in each term.

The above article is a timely reminder of the need for mental health care policies based on research evidence. At the beginning of this year the Australian Federal Government cut public access to psychological treatment via Medicare to 10 appointments with no exceptions. The research shows that even with the most brief forms of therapy, such as CBT and IPT (mentioned above), the recommended minimum is 15 to 20 appointments. At ten sessions, we know that only around a third of people will show clinically significant levels of improvement. That doesn't bode too well for recovery.

We are urging every Australian who feels strongly about the need for evidence-based mental health care policy to make a stand with us and sign our petition, which is on the front page of Change.org - you can find us at htpp://www.change.org/petitions/australia-needs-better-access-to-psychological-treatment

Please speak up on this. We will be presenting our petition to the Senate and our hope is that this will help our politicians see some sense. Cutting public access to psychological treatment is not the answer.

This is a wonderful blog. Thank you for sharing this. I believe that it is important the the surgeon or the physician should explain very well the procedure that his or her client will under go. This will lessen its anxiety if she knows exactly what is going to happen.