By Andrew Solomon, the author of The Noonday Demon: An Atlas of Depression and the national advisory board of the University of Michigan Comprehensive Depression Center (THE NEW YORK TIMES, 17/11/06):
Depression is the leading cause of disability worldwide, according to the World Health Organization. It costs more in treatment and lost productivity than anything but heart disease. Suicide is the 11th most common cause of death in the United States, claiming 30,000 lives each year.
Despite medical advances in the last 20 years that have greatly improved our ability to help those who suffer from depression, we lack an effective system for administering care. Only a very small percentage of depressives who seek help receive appropriate treatment for their condition. Research often stalls short of being translated into useful medicine. Depressives continue to be stigmatized, which makes their lives even more difficult and lonely. Finally, many sufferers are left to spiral, unsupported, into despair because their insurance companies refuse to pay for treatment.
These problems are similar to those cancer patients once faced, and the best way to address them might be similar as well. We need a network of depression centers, much like the cancer centers established in the 1970s.
Through the National Cancer Institute, federal funds were dispersed to interdisciplinary centers like Memorial-Sloan Kettering in New York and M.D. Anderson in Houston. The idea was to make sure that 80 percent of the American population lived within 200 miles of such a center.
As this network of institutions took root, the quality of cancer treatment advanced dramatically. The centers brought researchers and clinicians under one roof, ensuring that basic science was applied to achieve medical results. Scientists communicated both within and between centers, so that everyone could make use of everyone else’s work to accelerate progress.
Following this model, the National Institute of Mental Health should coordinate and subsidize a national network of depression centers, ideally based at research universities with good hospitals and departments devoted to the subject.
The University of Michigan, host to the country’s first national depression center, which opened its doors last month, has been a pioneer in this regard. More than 135 experts on depression and bipolar disorder will collaborate there, about half of them psychiatrists. The center has a large clinical treatment program and a genetic database that will house samples from tens of thousands of depressed and bipolar patients. It is sponsoring social and biological research and pressing for policy initiatives related to mental illness.
Among the thousands of depressed people I have met with, the majority have sought treatment but feel that they are not getting good care. Many of them have been prescribed antidepressants by family doctors who lack training in psychiatry and have conducted only cursory interviews before rendering their diagnoses. Antidepressants vary in their chemistry and effects; and human brains vary as much as human minds. To treat the most complicated organ in the body appropriately demands considerable expertise.
The question I am asked most frequently is how to get better care, and it can be devilishly hard to answer. Depression centers that could deliver a high standard of comprehensive care would be a dream come true — not only for millions of depressives, but also for the research community.
Last winter, the Library of Congress organized a conference where theoreticians met with mental-health consumer advocates and clinicians. The combination was unusual and wonderful. Everyone left with fresh ideas. We need formal bodies to sustain such fruitful intimacy.
Research related to a major disease should not unfold in a purely intellectual context, nor should consumer advocacy exist solely in a lobbying context, nor clinical practice exclusively under the shadow of profit-driven pharmaceutical research. (Full disclosure: my father is the chief executive of a pharmaceutical company that manufactures antidepressants.)
Before the cancer centers came around, cancer was as taboo as depression is now. But as antibiotics and vaccines for other illnesses lengthened life expectancy, cancer became more pervasive and less shameful. Depression, too, is becoming more widespread and more frequently diagnosed. Depression and bipolar illness will affect some 20 percent of Americans during their lives, and yet the stigma endures. People often come up to me after lectures to whisper about their affliction, as though everyone else in the room weren’t grappling with precisely the same thing.
It is neither wise nor feasible for a large proportion of the population to be trying to keep a secret. A national network that helped to medicalize depression in the public imagination would reduce sufferers’ shame. The very waiting rooms of depression centers would provide incontrovertible proof of the ubiquity of the illness and ease the isolation of sufferers. Within the centers, patients would find themselves the focus of an elite community of insight and support.
Alleviating stigma will also make it harder for insurance companies to deny treatment. As it is established that these mental illnesses are not character defects, but instead can be characterized in terms of brain symptoms, the false distinctions between them and cancer or heart disease will become impossible to sustain. The fiscal irresponsibility of leaving untreated an illness that causes enormous loss of productive work years would be clearly demonstrated.
We’ve made stellar progress in treating mental illness since the Prozac revolution but there is a catastrophic divide between research and practice. We must come up with a seamless way to support scientific progress and to administer the treatments we have, in order ultimately to alleviate as much suffering as possible.