Suzy Favor Hamilton was less than a lap away from the Olympic finish line when she fell.
But for the three-time Olympian long-distance runner, the collapse at the 2000 Sydney Olympics was no accident. Favor Hamilton was dealing with an injury and feeling immense pressure to win gold, so when other runners began passing her, she experienced a panic attack and purposely went down to avoid finishing last.
Favor Hamilton’s brother, who suffered from bipolar disorder, had committed suicide less than a year earlier, and she felt an intense need to win the race and lift her family’s spirits. She had experienced anxiety as a child but said that, just like her brother’s disorder, her worries were never talked about.
“(Anxiety) was always there as a child, but we just never addressed it,” Favor Hamilton said at a Marquette College of Health Sciences panel discussion Monday entitled “Depression: The Intersection of Hope, Medicine and Research.” “If I ran, my life was perfect.”
After her daughter was born in 2004, Favor Hamilton began suffering from depression and was given a prescription for Prozac, a commonly used antidepressant. She has since switched to a similar drug, Zoloft, but still takes antidepressants today and has accepted them as part of her life.
Favor Hamilton’s story was a focus of Monday’s event, which was attended by more than 300 members of the Marquette and Milwaukee communities and marks the beginning of the “Marquette Presents” series that will focus on community health. But it also highlights an ongoing debate in the mental health field over how best to balance medication and therapy in the treatment of depression.
A national problem
According to a national survey conducted by the Centers for Disease Control and Prevention from 2006 to 2008, nine percent of Americans meet the criteria for some form of depression, including 10.9 percent of those aged 18 to 24.
The overall prevalence of depression in the American adults was down three tenths of a percent since 1993, CDC statistics show. But according to CDC surveys conducted from 1988 to 1994 and from 2005 to 2008, the national rate of antidepressant use among all ages increased nearly 400 percent over a similar period.
Eleven percent of Americans aged 12 and older now take antidepressants, according to the CDC, making antidepressants the third most prevalent prescription drug used in the U.S. among all ages, and the most common among those aged 18 to 44, from 2005 to 2008.
The rise in antidepressant use should be deemed a success, Monday’s panelists said, to the extent that it corresponds with a destigmatization of mental illness and its treatment rather than a heightened need for medication.
“One of the barriers to destigmatizing (depression) is the idea that it’s a weakness of character,” said Paul Gasser, a panelist and a Marquette assistant professor of biomedical sciences, in a Wednesday interview with the Tribune. “The fact is that there are real biological differences.”
The panel’s focus on medication, Gasser and others said, was driven by a firm belief that the best way to eliminate that stigma is to focus on the biological, not the mental. Peter Lake, an Oconomowoc psychiatrist and another panelist, called antidepressants “a godsend” in his remarks to the audience. College of Health Sciences Dean William Cullinan, the fourth member of the panel that also included Favor Hamilton, said the rise of biological research on depression “leaves us with a great sense of hope.”
But for many of those affected by depression and those who treat it, the ascent of antidepressant use is cause for concern.
Multiple treatment options
The use of antidepressants has traditionally been paired with some form of psychotherapy, a combination that is intended to address both the symptoms and the underlying causes of depression. But according to the CDC data from 2006 to 2008, less than half of Americans who take multiple antidepressants, and less than one third of those who use even one such drug, had seen a mental health professional in the last year.
That trend could be caused in part by the length for which patients continue using antidepressants, as the CDC found that more than 60 percent of Americans who take antidepressants have done so for two years or longer, and 14 percent have done so for ten years or longer.
Katherine Sharpe, an author whose book “Coming of Age on Zoloft” was released in June, experienced the mental health industry’s tendency toward medication herself in college, when she went to her college health center and came away with a prescription for Zoloft, one that would be fulfilled for the next ten years.
“(Medication) has become our first line of treatment,” Sharpe said in a Wednesday interview with the Tribune. “But it doesn’t really help people understand why they’re having these symptoms in the first place. Defining the problem as a biological problem or a chemical imbalance can make them feel like there’s nothing they can do about it.”
That view runs counter to those of biomedical scientists like Cullinan and Gasser, and to an industry in which mental health professionals are turning increasingly to medication for treatment. The 2004 to 2005 National Ambulatory Care Survey found that only 10.8 percent of the nation’s 48,000 psychiatrists provided talk therapy to all their patients, down from 19.1 percent in 1996 to 1997. That number has steadily declined for years, as psychiatrists seek the efficiency of 15-minute prescription updates over longer, more traditional therapy sessions.
“It just means that they are able to treat more people,” said Michael Wierzbicki, a Marquette associate professor of psychology. “Is that kind of treatment more limited? Perhaps in some cases.”
But for other psychologists, antidepressant prescriptions can be a source of vexation. Sara Edwards, a Wisconsin psychologist whose work focuses on talk and equine therapy, said she can get frustrated when a client is making progress in therapy, only to go to a psychiatrist and receive multiple prescriptions. Edwards said in some rare cases, her clients have been put on up to five drugs: an antidepressant, an antianxiety medication to deal with the side effects of the antidepressant, a “booster” drug to amplify the effects of the first two, a mood stabilizer and finally medication to increase focus, which is normally used to treat attention deficit hyperactivity disorder.
“It’s difficult to watch clients try to manage that much medication,” she said. “Sometimes
without close monitoring by their physician, they get medications that are treating side effects of other medications.”
Part of the reason for the turn to medication is the reluctance of many insurance companies to cover psychotherapy, Edwards, Sharpe and others said. Even when therapy is covered, a psychiatrist can earn $150 for three 15-minute medication appointments, but only $90 for a 45-minute counseling session, according to a March 2011 article in the New York Times.
“Unless insurance companies will pay for therapy, you’re just having a nice academic discussion,” Sharpe said. “It really just comes down to dollars and cents.”
“(Insurance companies) don’t like to cover talk therapy because it takes more time,” Edwards said. “But that time is spent more effectively. Even though you may be medicating depressive symptoms, the conflict that causes those symptoms is still there.”
The decline of talk therapy in favor of medication checks was pointed out by the panelists Monday as well.
“I can’t even say hello and goodbye in 15 minutes,” said Lake, the psychiatrist. “The hour-long visits are still very important.”
Cullinan also acknowledged the effectiveness of psychotherapy, pointing out that it can have the same biological result as the use of antidepressants. But he said in terms of its causes, depression should be viewed purely biologically.
“I don’t really think that biological depression is based on any underlying conflict,” he said. “I think it’s just a biological entity. We need better treatments that work faster, but to go and search out this underlying source of conflict isn’t the way to go.”
A push for efficiency
To try to make treatment both more easily accessible and more affordable, six states considered laws last year that would allow psychologists, in addition to psychiatrists, to prescribe medication after completing some coursework, equivalent to a master’s degree in psychopharmacology. New Mexico and Louisiana have already passed such laws, and psychologists can also prescribe medication nationwide in all branches of the military as well as the Indian Health Service.
And according to a 2009 Consumer Reports survey of more than 1,500 anxiety and depression patients, 53 percent had received their prescriptions not from psychiatrists, but from their primary-care physicians. It’s a trend many mental health professionals view unfavorably.
“Sometimes the physicians are in too big a hurry to prescribe drugs without really having a good look at the whole situation,” said Anees Sheikh, a Marquette psychologist and professor of psychology. Cullinan agreed, noting that while antidepressants are often thought of as overprescribed, “they’re probably not over-prescribed by psychiatrists (but) rather by general practitioners.”
Treating depression quickly is becoming a motif throughout the field. Gasser and Cullinan spoke with urgency of the need to eliminate the three-week delay in efficacy that marks the beginning of antidepressant use, noting that those three weeks can be the difference between life and death in some cases. According to the CDC, approximately 4,600 lives are lost each year to suicide, the third leading cause of death for Americans aged 10 to 24.
Limited resources have also forced college health centers, including Marquette’s Counseling Center, to adopt short-term treatment models.
Although the Counseling Center focuses on talk therapy, its director, psychologist Michael Zebrowski, said he still has qualms about the haste with which some prescriptions are made.
“In some ways, pharmaceutical companies may educate about and destigmatize psychiatric medications more than other agencies,” Zebrowski said in an email. “But I do get concerned that people diagnose themselves, decide what might be a good medication for them based on little information, and then request it of their doctor.”
Chris Daood, the center’s assistant director, said in an email that because Marquette students are “intelligent and often highly motivated for change,” the short-term model works for “the vast majority of students who walk in our door.” Daood called cases in which a student would benefit from long-term treatment “rare.” Nevertheless, Sharpe said, colleges would be well served by a deeper investment in therapy.
“When the trustees are looking at the budget, more counseling hours and more sessions would be money well spent,” Sharpe said.
A search for meaning
Worries also remain about the side effects of antidepressants and other psychotropic drugs. According to the Mayo Clinic’s website, these side effects can include nausea; increased appetite and weight gain; sexual side effects, including erectile dysfunction; fatigue and drowsiness; insomnia; dry mouth; blurred vision; constipation; dizziness; and agitation, restlessness and anxiety.
But according to Edwards, “what people struggle with the most is they feel not like themselves. It makes people feel less reactive, so they end up feeling less emotion. It can numb everything, not just depression.”
Those who see depression as purely biological often equate it with other non-mental illnesses in an effort to destigmatize. As Gasser put it, “the stigma that’s not present for someone who has diabetes should not be there for someone who’s got a mental health disorder.”
But that paradigm doesn’t always prove helpful. Meghann Rosenwald, the president of Marquette’s chapter of the mental health organization Active Minds, said her awareness efforts center on the effects of mental illness, not its causes.
“I’m in the College of Health Sciences, so I understand the role that medication plays in this,” said Rosenwald, a junior. “But when you’re actually getting down to the education of it, we don’t talk as much about antidepressants.”
For many, the complexities of depression have simply made it inexplicable, as Gasser explained to the panel’s audience Monday.
“If you can describe your depression, you may not have actually had it,” he said.
But in other ways the debate over how best to treat depression reflects a deeper philosophical debate between the sciences and humanities, the quantitative and qualitative. Gordon Marino, a professor of philosophy at St. Olaf College and the editor of “Basic Writings of Existentialism,” wrote in the book’s introduction about his own struggles with depression and his ensuing turn to existentialism, which seeks meaning in life through personal human experience.
“One of the problems with the purely biological approach is that when people become fundamentalists about it, they don’t think about the meaning of it at all,” Marino said in a Wednesday interview with the Tribune. “A lot of people use medication to avoid doing that. I do think it’s important to reflect on our experiences and what we’re feeling.”
Those reflections, Edwards said, can make a remarkable difference.
“I truly believe psychotherapy works, and when it’s done well, it works extremely well,” she said. “People who are in psychotherapy can be the healthiest people in a community, because they are working on their relationships with themselves and with others.”
But regardless of the approach taken to treating depression, Gasser said, the individual case must be the focus.
“It’s probably easier in many ways to just take a pill than it is to talk about your problems,” Gasser said. “But this is an individual disease – there’s no one cause. (Treatment) has to be an individual thing.”