Ellen Hackett at home. All images by the author.

Here, Take This: New Zealand’s Over-Reliance on Antidepressants

The country’s help services are at breaking point, but does this mean pills should be the first and sometimes only treatment for depression?

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21 January 2019, 1:22am

Ellen Hackett at home. All images by the author.

Her two kids are busy splashing in the bath. Water is spilling over the edge and onto the monochrome tiled floor. She watches the puddle grow.

The phone rings. It’s her husband apologising that he won’t be home till later on. And without realising, this tips her over the edge, an edge she had been tiptoeing along for weeks.

“I just snapped, completely snapped. And I knew that something was really wrong,” she reflects.

She dials the crisis line, and frantically explains how she feels out of control. Like she is crawling in her own skin.

“I just don't know how to stop feeling like this. I am completely losing the plot, I don’t know what to do, and I am really scared. I have kids in the bath, and no one else is here, I need help,” she tells the calm, empathetic voice down the line.

“They told me to go outside and have a cup of tea,” she laughs.

But she keeps pressing. Knowing if she doesn’t, she won’t be able to afford the help she needs. For Sarah* is no stranger to New Zealand's mental health system. Diagnosed with depression 20 years ago, she has no problem getting her hands on medication, but the counselling that may help more seems always out of reach.

“I started to get more and more desperate with them. And nothing, nothing, nothing. They said they were busy, which I am sure they were. It was Friday night, so probably high peak time for them.”

When her husband arrived home, she drove herself to White Cross, thinking someone there could help. But all they could do was call the crisis line, and they got the same answer: “We are busy.”

As the clinic was closing, the receptionist tried Auckland Hospital, asking if she could go there. But they said they couldn’t help her either and suggested calling the Police. So they did.

Now 11 o’clock, a policeman collects Sarah and takes her to Avondale Police Station. They call the crisis team themselves, and this time they do come—eventually.

But despite everything she tells them, she is left with just a sleeping pill and told to head home.

“I saw my GP the next day and was put on medication but not once have I been offered any counselling, or anything like that. It is all about the drugs.”

*

Sarah is one of thousands of New Zealanders locked out of funded therapy because their mental illness is not severe enough. Instead, they are left holding a packet of pills. It’s an approach experts are deeming “the wrong way around”, but with a mental-health system starved of funding and antidepressants cheaper than ever, is there any other option?

Aotearoa’s Mental Health and Addiction Inquiry, titled ‘He Ara Oranga’, was released in December last year and revealed just how prolific this exclusion is. The report listened to the voices of New Zealanders being treated by, or working in, a system in crisis and found that only targeting specialised help services to three percent of the population is not enough. Especially when current research shows one-in-five Kiwis experience mental health and addiction challenges at any given time. Instead, it suggested initiating an access target of 20 percent to reach the “missing middle”—the people who are severely distressed but told they are not severe enough to access funded help, yet.

The report argues that when a mental-health system focuses almost entirely on those who have the most severe needs, the opportunity for early intervention is lost. And without help in the early stages, a person's mental state can quickly deteriorate, eventually putting more pressure on a system that is already struggling. By dedicating new services to mild-to-moderate mental disorders, the system will become the fence on top of the cliff, not the ambulance at the bottom.

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Most people who have seen a doctor about depression will be familiar with the Kessler Psychological Distress Scale, the K10 for short. The multi-choice questionnaire asks you to rank how you have been feeling recently on a scale of 1-5.

Your GP will tally up your score and this number will help indicate whether or not you essentially “qualify” for funded therapy. Only those with a score greater than 25 are considered for the six free sessions provided through ProCare.

But with a system at breaking point, there is no guarantee of immediate one-on-one treatment for anyone. A 2018 Ministry of Health report revealed more than 1500 under 18-year-olds are waiting longer than two months to see support services.

Bev Weber, New Zealand Association of Counsellors (NZAC) National President, said “a referral to a counsellor should always be the first option for anyone seeking help for mild-to-moderate mental health issues. But a lack of funding means this is unrealistic for everyone.”

Nelson Bays Primary Health, for example, saw 752 people in the first six months of last year, but the clinic is only funded for 712 “packages” for mental health care for the entire year. Weber said this is not a unique case, and the gap between the demand and resources continues to grow across the country.

There simply isn’t enough help to go around. And this often means only the most severe or at-risk cases get seen. But what about everyone else? Could this mean GPs are relying more on antidepressants alone to treat those with mild-to-moderate depression? And is it helping?

*

We step into Ellen Hackett's bedroom. The walls are painted a mossy green, a backdrop for the plants and books arranged on floating shelves. She hurries to shift a pile of clothing and towels off her mattress and onto the wooden floor, then invites me to sit in the clearing.

She apologises for the mess and tells me it has been an overwhelming week. She looks down at her crinkled pyjamas, “I haven’t even gotten dressed yet.” It’s four in the afternoon. “One of those days,” she laughs.

Hackett first saw her GP about her depression and anxiety three years ago. She tells me that grappling with her sexuality and body image fuelled her mental deterioration. “I was living and doing things so I obviously didn’t have major, crippling depression. But I did not want to be here. I harmed myself, I was considered a danger to myself during that stage in my life.”

But after confiding in her doctor, she was told she was not “technically eligible” for funded counselling. Still classed as “moderate”, she assumes she didn’t meet the criteria. “He didn't explain anything, he just said you are not eligible, you can go now. There was no discussion, no explanation why. There was no empathy or support, I was just his next client in the waiting room.”

Hackett left her appointment holding a script for Citalopram, a popular antidepressant, and a print out of Beating The Blues, and online Cognitive Behavioural Therapy programme. She was full of despair, knowing this was all she could afford to access.

She eventually saw a more compassionate doctor who was determined not to let a technicality get in the way of help, and Hackett finally received funded therapy sessions. She tells me that without them, she couldn’t imagine how she would’ve climbed out from that dark hole. “You have these thoughts and they are not just going to go away when you swallow a pill, you have to actively change your thoughts and how you perceive them. That’s what did it for me.”

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Auckland GP Dr Cleone Armstrong.

Research and best practice guidelines in New Zealand suggest talk therapy is the most effective treatment for milder forms of depression. But if that doesn’t help, medication can be introduced and the combination is usually successful.

But clinical psychologist and Auckland University associate professor Dr Claire Cartwright said because of drastic shortages, drugs are the first point of call and sometimes counselling isn’t even part of the conversation. “Quite a few GPs still refer to counselling but they are conscious it is going to be difficult for them to get it free or affordable. So in some cases, they might not actually even mention it,” she explains.

An Auckland GP, Dr Cleone Armstrong, admits she is relying more on antidepressants in isolation as the treatment for mild to moderate depression “because there just isn’t anything else to do.”

She works at Herne Bay Medical Centre and in the Waitakere Hospital Emergency Department and said nearly every day a new person will see her about their deteriorating mental state. “The mental health people, there just aren’t enough to go around so they can not offer a service to people who have got a mild problem,” she said. “And the alternatives really, there aren’t any. Unless you have got money.” A private therapy session can range from anywhere between $100 to $180, and sometimes more for a psychologist.

Chair of NZMA General Practitioners Council Dr Jan White said regardless of the severity, if an individual’s depression has a clear trigger then it is “absolutely imperative” they see a counsellor to work through it. “If a person is depressed because of some event or trauma and all we do is give them medication for it, I don't think we are making it worse but, we are certainly not making their recovery easy because we are not addressing the root cause.”

Dr White said recovery for mild to moderate depression on just medication is possible, but that it would take considerably longer. “If this type of depression requires medication, then they would be on them for about 12 months. However, coupling it with psychological support means you are much more likely to be at the six months mark when you can get rid of the drugs,” she said.

In the past 10 years, the use of antidepressants in New Zealand has drastically increased. Overall, 299,958 people were prescribed and collected the drugs last year, an increase of 64.9 percent over the last 10 years. The number of children and teenagers taking Prozac-style antidepressants has also doubled in that time.

Dr Cartwright said this was concerning, because not monitored properly, some antidepressants can increase the risk of suicidal ideation—serious thoughts about suicide—in young people. "I would rather see young people getting help with whatever is causing the depression because that sets them up well for life, rather than just going on antidepressants."

"They work for some people, and not for others. But even if they do work, the person is going to need to come off them at some point and the issues that lead to the depression in the first place may still be there."

Dr Cartwright said PHARMAC has steadily reduced the price of these pills, making the gap between the cost of medication and therapy grow even further. This has led to a rapid rise in prescriptions, because there isn't much else out there for those who cannot afford private treatment.

The Royal New Zealand College of General Practitioners spokesperson Lily Ng said population growth and the awareness and acceptance of mental health conditions have resulted in the rise in antidepressants. It does not necessarily mean these drugs are being overprescribed. “In the past, it is probably more likely that common mental health disorders such as anxiety and depression were left undiagnosed and untreated,” she explains. “For example, the Ministry of Health said that the number of Māori seen by DHBs for a mental health concern in 2015/16 was 4829 per 100,000. That is a rise of over 72 percent since 2001/2002.”

In a statement, Minister of Health Dr David Clark called the recent Mental Health and Addiction Inquiry a “once-in-a-generation opportunity to rethink how we handle some of the biggest challenges we face as a country… It is clear we need to do more to support people as they deal with these issues. The Inquiry heard many stories of people who did not get the help they needed and deserved. We must listen to these voices of people with lived experience.”

New Zealand’s mental health system is set up to deal with those diagnosed with a severe mental illness, but it does not offer enough or sometimes any support to those who are in the early stages of mental deterioration and yet are still significantly distressed. The inquiry found that even when help services respond to Kiwis with mental illness, the care is often through a narrow lense. “People may be offered medication, but not other appropriate support and therapies to recover… we do not have a continuum of care and support.”

The inquiry found that “we can’t medicate our way out of the current crisis” and it is the investment in practical help services that will make the difference. In order to make these goals a priority, the inquiry insisted there needed to be a clear shift in policy that recognises a need for supporting those with mild to moderate mental illnesses, a trained workforce and commitment to funding a wider range of therapies, especially talk therapies. “We need to ensure practical help and support in the community are available when people need it, and government has a key role to play here,” the report reads.

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Green MP Chlöe Swarbrick.

Green MP Chlöe Swarbrick was assigned her party’s mental health portfolio last year and has since travelled around university campuses to discuss students’ concerns with the current system. “I am here to get a sense of what is actually going on. I think it is really important to recognise that structural change, legislation, regulation and funding only happens when we have an environment that is culturally conducive to that change,” she said. "So it’s about having a conversation, ensuring that people actually know what is happening and shifting the stigma around our mental health.”

The Government is now on the hunt for an agency to run a $10.49m mental health pilot, giving 18-25-year-olds access to free talk therapy. The Green Party policy is expected to run for three years and will target young people with mild-to-moderate depression, who can not access other existing free services.

Associate Health Minister Julie Anne Genter said in a statement the pilot will provide information around what treatment works in a New Zealand context. “Too many of our young people have been left without support when they need it. We need to intervene early to ensure problems don’t become tragedies,” she said.

Since Sarah’s visit to the police station in search of help five years ago, she has been diagnosed with bipolar disorder alongside her depression. She said without support from her family, she would not have been able to afford the appointments with a psychologist that formally diagnosed her and gave her coping strategies.

But still unable to access funded counselling, Sarah had to cut the unaffordable session short and go back to just medication. She said she is exhausted with waiting for more help.

"The thing that really is frustrating is that when you want to get the help, but you are still not being able to get it. It actually can take a lot for a depressed person to want to get help. And so when we are reaching out, you don't want to shut us out. Because then we might give up."

Need to talk?
Free call or text 1737 any time for support from a trained counsellor
Lifeline – 0800 543 354 or (09) 5222 999 within Auckland
Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)
Healthline – 0800 611 116
Samaritans – 0800 726 666

*Not her real name.

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