Doctors treating people with depression should see it as a cue for personal change and not simply slate it as a blight for removal.
When a surgeon locates an inflamed appendix, on the verge of rupturing and spilling its putrid contents into the pristine peritoneal cavity, they rightly excise and discard it into the nearest hazardous waste bin. A life is saved and the appendage will not be missed.
Depression also kills; across the world suicide takes the lives of over 800,000 people each year and is the second highest cause of death in 15 to 29 year olds. It is understandable, then, that many seek to banish depression with the efficiency and precision of the surgeon’s knife—and to do so with antidepressant medication.
In the United States (US), three-quarters of people with depression treated as outpatients receive antidepressant medication, while 9 per cent of Americans, according to the National Center for Health Statistics, take an antidepressant for depression or a related disorder. Reflecting how speedily depression can be dealt with using pharmacotherapy, in the United Kingdom the average consultation time for a person with depression is just eight minutes.
However, most grades of depression can be treated as effectively with an evidence-based psychotherapy such as cognitive behavioural therapy or interpersonal therapy. But, while antidepressant prescription rates in the US remained constant in the decade to 2007, utilization of psychotherapy fell from 53 percent to 43 per cent.
Although psychotherapy has gained prominence in depression treatment guidelines, monotherapy with antidepressants still fits the remit of many. That means doctors can fulfil their duty of care to depressed patients by tallying their symptoms against those in the DSM V, gauging severity on instruments such as the Hamilton Depression Rating Scale, and simply prescribing an antidepressant if the relevant criteria are met.
Indeed, there are prima facie reasons to support an approach that simply aims to be rid of depression; not only is it distressing and sometimes lethal, but depression is now the leading contributor to the global burden of disease in high and middle-income countries.
I will argue, however, that an ethically defensible approach to treatment should not aim to remove depression as one would a diseased appendix. Rather, treatment should transform depression by discerning its value as an insight into various threats to the sufferer’s interests. To that end, doctors must recommend psychotherapy, either stand-alone or as an adjunct to antidepressants, in all cases of major depression.
Biegler P. Is treating depression just like treating appendicitis? In Charles Foster, Jonathan Herring (Eds) Depression: Law and Ethics. Oxford University Press 2017.
Read my full book chapter from this edited collection here.