By DONNA URSCHEL
The advertising of drugs for depression, the over-prescription of those drugs, the effects of antidepressants on creativity and the future of depression treatments were several topics covered by two medical experts in a discussion about depression at the Library on April 19.
William Safire, New York Times columnist and chairman of the Dana Foundation, moderated the talk titled "Demons of the Mind: 21st Century Science vs. Depression." Participants were Carl Elliott, M.D., Ph.D., professor of pediatrics and philosophy at the University of Minnesota's Center for Bioethics, and Steven E. Hyman, M.D., provost of Harvard University and professor of neurobiology at Harvard Medical School.
Safire launched the discussion by asking Elliott about the dangers of consumer advertising of antidepressants. Elliott said, "It leads to over-prescription, an over-prescription of drugs for people for whom the drugs are not a medical necessity but more a matter of desire."
Hyman disagreed with Elliott, saying doctors deserve some credit. "Even if a patient didn't meet the narrow criteria for major depression, if he or she was unhappy and suffering symptoms, and especially suffering some disability in life, I would do a therapeutic trial. I'd say try the medicine, come back in four weeks and see if it made you feel better. I think we have to give the public and doctors credit to work it out privately."
Although he did not offer any statistics, Elliott said the incidence of depression was much lower in the 1930s, '40s and '50s. "What accounts for the huge difference? Are more Americans depressed [today]? Do we live in more depressing times? Are psychiatrists more able to diagnose it?"
Hyman said he did not think Americans of the '30s, '40s and '50s answered questions about depression honestly and were not willing to admit that they or a family member had a mental illness. There was too much stigma attached to the condition. Today, through education and consumer advertising, Americans know more about the disease, are less ashamed and more willing to get treatment, according to Hyman.
"The world is a better place when people come forward and get treated. But the main problem today is still under-treatment and not over-treatment," Hyman said.
Safire cited a study that says five times as many poets and novelists are afflicted with bipolar disorder (also known as manic depression) than the general population. "If we treat depression, will it also take down creativity?" he asked.
Hyman said treating depression doesn't necessarily result in loss of creativity. He referred to a study about lithium (a drug for manic depression) and creativity. He said the results showed a mixed picture: Some patients needed their mania to be creative, other patients were more creative on the medicine, and yet others experienced no difference in their creativity.
"More seriously, as a physician, if someone who is suffering wants treatment, it is not my job to worry about some work of art that might not be created," Hyman said. "Treating these people is most important. Whether we lose at the margin an artist or two is not my concern."
Safire also asked about the future of psychotherapy in this age of biochemistry and the availability of antidepressants. "Is there a Freud in our future?" Safire said.
"Not old Sigmund," Hyman answered. "He was a brilliant man with lots of insights that probably were not relevant to mental illness, but there are a lot of psychotherapies, like cognitive behavior and interpersonal therapies, that are effective."
Safire asked Hyman to look ahead 10 years and discuss the state of depression and its treatments. "Well, I hope by 10 years we would have four things," Hyman said.
"First, I hope we have both new pharmacological interventions and psychotherapies that are more effective," he said. Although the drugs we have today are good, far better than in the 1950s, about one-third of the patients taking antidepressants do not benefit much from the medication, Hyman explained.
"Second, we need to continue to erode the stigma," he said. Even among the most sophisticated people there is a reluctance to admit having a mental illness. "Third, we need to make sure the family doctors have the expertise to treat depression. There will not be enough psychiatrists, and the family physicians will be handling many of the cases. And fourth, we need policies that treat mental illness like all other diseases, because it is a real disease."
Elliott, however, isn't comfortable calling depression a disease, like cancer or diabetes. "Depression is never simply a matter of molecules," he said. Elliott thinks changes need to be made to the environment and in society, such as reducing stress and unreasonable expectations. He said grief, shyness and alienation are sometimes reasonable responses to the way we live and not necessarily grounds for a mental disorder. "We need less television and fewer shopping malls," he joked.
Elliott thinks there is an explosion in "enhancements," wanting to feel better and look better, because the market system today creates conditions for depression, then enlists doctors to sell the treatments. "My problem is when doctors see themselves as salesmen," Elliott said.
Safire wrapped up the discussion by describing the optimism among scientists and doctors about future treatments of the brain. "We've learned more about the brain in the past three to four years than in all of history. The new technologies have helped. The excitement in the world of the brain is an inspiring thing," he said. Safire heads the Dana Foundation, a private philanthropic organization with interests in brain science, immunology and arts education. It was founded in 1950.
The Dana Foundation, the Heinz Family Philanthropies, the National Institute of Mental Health and the Office of Scholarly Programs at the Library of Congress sponsored the discussion, held in conjunction with a private two-day conference on depression.
Donna Urschel is a public affairs specialist in the Public Affairs Office.