FIONA BARBER asks actor Ian Mune and clinical experts if Prozac really is the best way to treat the blues.
He has played Shakespeare's crazed King Lear. More recently, he has put his face to the Like Minds, Like Mine televised campaign, a project aimed at dispelling prejudices about mental illness.
Over
coffee in a cafe next to Wellington's Downstage Theatre where he was rehearsing his latest play, actor and director Ian Mune talks frankly about depression.
Looking back more than two decades, the world appeared to him like a big bowl of custard. Mune was in the throes of depression and friends suggested he might need to talk to someone, so he went to a counsellor. "I would have been a mug not to," he says.
The sessions started with his whole family. "It was pretty soon sorted out that the kids weren't the problem. Then it was prettily easily sorted out my wife wasn't the problem. That left me."
The counsellor told Mune she needed to talk to him and she suggested it should be a long session. The therapy did not solve his problems but it defined them so he could work his way through them. He's never needed to return to the counsellor, despite occasional bouts of depression which he says he has learned to live with.
Mune's life was put back on track by the sessions. That doesn't mean he would rule out using antidepressants. If he needed them, he'd give them a go, he says.
"Right now I've got a sore knee and I'm taking Voltaren. Voltaren doesn't fix my knee but it eases the pain so at least I can walk around. I think that's how these things work."
Which is pretty close to how some health professionals view the role of antidepressants. The drugs are useful in lifting people's spirits but should not be used as chemical sticking plasters which cover the wounds of depression but do not let them heal.
Enter the debate about whether drugs or counselling, or combinations of both, are needed to treat depression. And do the costs of each influence patients' and doctors' decisions?
The tally of people prescribed antidepressants has ballooned from about 150,000 in 1993 to 241,000 last year.
A psychiatrist who developed official guidelines for treating depression says drugs should never make up the entire treatment package.
Pete Ellis, professor of psychological medicine at the Wellington School of Medicine, says antidepressants play an important role in treating depression. "There is a significant biological component to one's vulnerability to depression."
But he also points out an apparent inequity in other potential remedies, the sort of sessions which helped Mune. While the pills are Government-subsidised, there are few or no subsidies for sessions with psychologists. "It's an issue of social equity and consumer choice," Ellis says.
Health Minister Annette King says she will take advice from officials on the issue but she stops short of promising any action. She has approved the setting up of a mental health workforce advisory committee.
As a result of Government subsidies on antidepressants, at least some pills are in the financial reach of most, if not all, of those prescribed them. A wage-earning adult prescribed one of the new-generation antidepressants like Aropax or Prozac can pay as little as $15 a month for the drugs. For those in tougher financial straits the cost is even less, and in some cases they are free.
Thirty tablets of the fully subsidised Aropax cost anywhere between nothing and $15. Prozac, which is not subsidised to the same level or has a "manufacturer's surcharge," costs the patient up to $52.50, although patients prescribed the generic versions of the drug will pay up to $15.
The situation is not so straightforward for people wanting additional or alternative counselling to help them to deal with depression. Patients can be referred to public community mental health centres but can face waits of up to a month if they are not deemed to be in urgent need. Health officials say urgent cases are always seen immediately by specialist teams.
Sessions with privately practising counsellors or psychologists can cost up to $150, so sometimes the pills appear to be the cheapest and quickest solution.
Despite the ballooning of prescriptions, Ellis says he doesn't get a sense that New Zealand doctors are over-prescribing. "We won't get it all right all of the time. I don't think we're significantly out of line with international practices."
Among the reasons for the hike in prescriptions is more awareness of depression and treatments for it, as well as patients who once shunned the older-style drugs because of side-effects now deciding to try the new-generation pills such as Aropax and Prozac.
(The latter is now under the international spotlight in the wake of emerging claims that some patients can become belligerent and pose risks to themselves and others.)
Recent local research backs Ellis' call for more affordable, non-chemical options.
Jan Wilson, a counsellor at AUT, carried out research into such options for her masters degree in psychology at Auckland University. As part of her work she sent questionnaires to North Shore and West Auckland GPs asking about treatment resources for depressed women.
Of the 55 medics who responded, almost 70 per cent said they wanted counselling and psychotherapy to be more readily available. Ninety-six per cent wanted such therapy to be as affordable as GP visits.
One doctor replied: "I would use a lot more counselling if it were freely available but the people who most need it cannot afford it. There's relatively few young people who can afford $85 an hour. A lot of my older patients can't either."
Sixty-seven per cent of the GPs mentioned concern about waiting times in the public mental health system, and 44 per cent were worried about the cost of private counselling and psychological therapy.
The survey also revealed a widely held belief that life stresses and biology could be behind depression. Some people present very much on a physical level without any apparent precipitating causes, while others have many other stresses.
Dr John Read, a senior lecturer of clinical psychology at Auckland Univer-sity, also calls into question the lack of backing for other types of treatments.
"A subsidy for counselling would save massive amounts of money on drugs, loss of work, loss of productivity in the workforce. It would be very much a long-term investment."
He says some patients cannot afford counselling and, as a result, end up with drugs alone. According to Read, who supervised Wilson's work, most private sessions with a counsellor or psychologist cost between $50 and $150.
"You can ask a GP to refer you to a community mental health centre and ask to see a psychologist," he says. "How-ever, there are not enough psychologists employed and there can be a long waiting time."
But Read says often a small number of sessions with a counsellor or psychologist can make a real difference to someone's life. He cites research which claims that in the short term, drugs and psychological therapy achieve similar results in relief and sticking with the treatment.
Longer term, however, more people tend to drop out while taking medication, often because they do not like the side-effects, while those having some form of counselling relapse less often.
"By far the most powerful determinant of whether you feel depressed is how many depressing events have happened."
But Read concedes there is a place for drugs — in serious cases — and that counselling is not a panacea.
"In severe cases of depression, it can be helpful in the short term to lift someone's mind artificially so they are able to mobilise other resources and have the energy to deal with what is depressing them."
A 1997 survey showed that 31 per cent of British GP practices had counsellors or clinical psychologists attached to their surgeries, and Read would like to see that happen here.
Another trend from the coalface shows that Tranx, the organisation which tries to help people break the shackles of tranquilliser and alcohol addiction, is now seeing clients in Auckland who are also taking antidepressants.
"Our world is speeding up and everyone wants an instant fix," says clinical services manager Shaz Picard. "We don't have the time, we're in a very fast world. If there's an instant fix, people will grab it."
In Mune's case, he was able to make time for several months' counselling, and payment was on a donation basis.
"We were asked for a contribution. I don't think our contribution was very big. We were very broke at the time."
As the coffee is drained from his cup, he puts his encounter with the illness into context.
"I don't know anyone who hasn't suffered from depression. If I did find such a person, they would probably be rather boring."
FIONA BARBER asks actor Ian Mune and clinical experts if Prozac really is the best way to treat the blues.
He has played Shakespeare's crazed King Lear. More recently, he has put his face to the Like Minds, Like Mine televised campaign, a project aimed at dispelling prejudices about mental illness.
Over
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