Better treatment for depression
===============================

* Alain Lesage

How can the recent *CMAJ* editorial on depression recognize the grief that followed Robin William’s suicide and yet be so despairing by stating that depression deserves better treatment?1 The tragedy is not just that so many people have depression or that despite good treatments some will lose their battle, but also that our society does not make treatment universally accessible.

During a roundtable discussion of the Canadian Depression Research and Intervention Network in the spring of 2011, then Minister of Labour Lisa Raitt argued for a better strategy on mental health in the workplace. Raitt detailed her experience with depression after the birth of her second child. Her general practitioner convinced her to take antidepressants, and she has recovered well. Hers is but one example.

Large transnational studies show that increased sales of antidepressants are associated with a significant decrease in suicide rates in adults and a lesser one in adolescents.2,3 The opposite effect occurred when black-box warnings appeared on antidepressants for adolescents: there was an increase in suicide in the following year.4 There was also a decrease in the treatment of depression by physicians and in the number of prescriptions for antidepressants. If we interpret this through the perspective of the general theory of psychotherapy and apply it to anti-depressant treatment, the black-box warnings sent a despairing message to physicians that treatment may be more dangerous than beneficial, and to patients and families, that treatment may not work.

A recent population survey by Statistics Canada on mental health and well-being assessed the perceived needs for care: the need for medication was largely met, but the need for psychotherapy was not.5 Medication is easily accessible in Canada, with many provinces providing universal coverage. However, this is not the case for psychotherapy. In a publicly managed health care system like Canada’s, what is not insured is simply not accessible.

Australia and Great Britain have increased insured access to psychotherapy services. In Australia, psychotherapy prescribed by a general practitioner and delivered by an accredited psychotherapist is reimbursed through the Australian physicians’ billing insurance plan. The result has been an increase, from 37% to 47%, in the treatment of common mental disorders.6 Studies on the effectiveness of psychotherapy in Australia and Britain show that, on average, patients will require five to six sessions and that the effect sizes will be large (circa 1). For instance, 70% of patients at intake will meet criteria for moderate depression, while only 20% will do so after treatment.7,8

What message should Canadian physicians give to their patients with depression? First, there are effective treatments for depression and second, what is medically required should be insured to provide improved access.

I invite Canadian physicians to join coalitions to ensure equitable access to treatments, like the Graham Boeckh Foundation ([www.grahamboeckhfoundation.org](http://www.grahamboeckhfoundation.org)).

## References

1.  Patrick K. Depression deserves better treatment. CMAJ 2014;186:1043.
    
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5.  Sunderland A, Findlay LC. Perceived need for mental health care in Canada: results from the 2012 Canadian Community Health Survey: Mental Health. Ottawa: Statistics Canada; 2013. Available: [www.statcan.gc.ca/pub/82-003-x/2013009/article/11863-eng.htm](http://www.statcan.gc.ca/pub/82-003-x/2013009/article/11863-eng.htm)
    
    

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8.  Pirkis J, Ftanou M, Williamson M, et al. Australia’s Better Access initiative: an evaluation. Aust N Z J Psychiatry 2011;45:726–39.
    
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