In contrast, before the 1970s, depression was usually considered a relatively rare condition involving feelings of intense meaninglessness and worthlessness often accompanied by vegetative and psychotic symptoms and preoccupations with death and dying (Shorter 2009). Moreover, depression was more likely to be associated with hospitalized patients than with clients of general physicians or outpatient psychiatrists. But beginning in the 1970s until the present, depression rather than anxiety has become the common term used to indicate the breadbasket of common psychic and somatic complaints associated with the stress tradition. Depression now dominates clinical practice, treatment, and research in psychiatry as well as images of mental health problems in the broader culture (Horwitz and Wakefield 2007).
The global conception of stress-related problems in the 1950s and 1960s affected mental health research as well as treatment, so the most prevalent categories of research in the major psychiatric journals explored both general topics (e.g., behavioral science) and policy issues (e.g., mental health services) (Pincus et al. 1993). Particularly during the last half of the 1960s, these journals featured publications using a psychosocial framework. Research on mental problems in the community also relied on measures that reflected a nonspecific view of psychic disturbance, although they emphasized symptoms of anxiety (Horwitz 2002). But because depression was associated with psychotic symptoms, questions about this condition were rarely found in epidemiological surveys.
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Miltown became the most popular prescription drug in U.S. history. By 1965, physicians and psychiatrists had written 500 million prescriptions for it (Smith 1985, p. 316), and as early as 1960, about three-quarters of all American physicians were prescribing Miltown (Tone 2009, p. 90). By the late 1960s, however, the spectacular success of the benzodiazepine Librium, which was introduced in 1960, displaced Miltown. In turn, Valium succeeded Librium as a blockbuster antianxiety drug, becoming the single most prescribed drug of any sort: 20 percent of all women and 8 percent of all men reported using a minor tranquilizer each year (Parry et al. 1973).
Then, beginning in the 1960s, clinicians and researchers started to pay more attention to depression, especially emphasizing its prevalence among patients in primary medical care (Ayd 1961). This led advertisers to begin to place ads for the antidepressant tricyclics and monoamine oxidase inhibitors (MAOIs) in medical and psychiatric journals. By the end of the decade, the disparity between anxiety and depressive diagnoses thus had narrowed, although anxiety was still far more common than depression. In fact, depressive diagnoses in outpatient treatment grew to 8 million, whereas those of anxiety remained at around 12 million (Herzberg 2009, p. 260).
In contrast, the rates of any anxiety diagnosis for treated patients rose much more slowly, from 10.5 percent in 1987 to 12.5 percent in 1997 (Olfson, Marcus, Druss, and Pincus 2002). By 1996/1997, however, diagnoses of mood disorders were more than three times as common as anxiety diagnoses in office-based psychiatry (Mojtabai and Olfson 2008). A large study of psychiatric practice that the American Psychiatric Association (APA) conducted in 1997 is illustrative, finding that more than half of patients had mood disorders and about a third had a principal diagnosis of MDD, whereas just 10 percent had received a diagnosis of an anxiety disorder (Pincus et al. 1999).
Conversely, from 1996 to 2001, the number of users of SSRIs increased rapidly, from 7.9 million to 15.4 million. By 2000, antidepressants were the best-selling category of drugs of any sort in the United States; fully 10 percent of the U.S. population was using an antidepressant (Mojtabai 2008). In fact, these drugs were used so widely in general medical practice that in 2003/2004, 310 of every 1,000 female patients received a prescription for an antidepressant (Raofi and Schappert 2006). Prescriptions for SSRIs continued to grow, and by 2006, Americans had received more than 227 million antidepressant prescriptions, an increase of more than 30 million since 2002 (IMS Health 2006). Antidepressants were prescribed for mood and anxiety disorders alike, gaining unchallenged control of the market once held by the anxiolytic drugs (Mojtabai and Olfson 2008).
The unifying concept of DSM-I and DSM-II was that the symptoms of all psychoneuroses were defenses against underlying anxiety. A successful attack on this etiological concept required the wholesale destruction of its global concept of anxiety. As an alternative, the DSM-III developed definitions of various specific conditions underscoring that each was a discrete and qualitatively distinct disease (APA 1980). Unlike the DSM-I and DSM-II, which had placed both depression and anxiety within the same psychoneurotic category, the DSM-III formulated anxious and depressive conditions as completely different. It also carved away conditions such as hysteria and hypochondriasis, which had previously been core aspects of anxiety-related states, putting them into distinct groups. The psychoneuroses were split into four separate general categories: anxiety, affective, dissociative, and somatoform disorders.
Subsequent research illustrates the impact of the differentiation of anxiety into a number of disorders without a focus on any particular condition. After 1980, the vast majority (83 percent) of studies published in psychiatry, psychology, and related fields centered on a single anxiety disorder (Norton et al. 1995). These journals featured panic disorder/ agoraphobia (36 percent), PTSD (28 percent), and obsessive compulsive disorder (27 percent) to an almost equal degree. Less than 10 percent of the articles were on generalized anxiety disorder, which had been the central anxiety condition in psychodynamic theory. Current studies of anxiety remain balkanized and without a central focus (Boschen 2008).
In contrast, many patients reacting to stressful psychosocial contexts could meet the MDD criteria. Bereavement was the sole relevant exclusionary criterion for depression: someone grieving the death of an intimate who otherwise met the MDD criteria would not be so diagnosed so long as his or her symptoms were not especially severe or long lasting (APA 1980, p. 213). But no comparable exclusions were made for people who met the criteria after they were laid off from jobs, rejected by romantic partners, or informed of a serious medical diagnosis for themselves or an intimate. Unlike the diagnostic criteria for the anxiety disorders, the MDD criteria did not preclude diagnoses even when the symptoms were proportionate responses to the losses that provoked them. The range of conditions in the stress tradition that featured mixed depressive and anxious symptoms thus became more amenable to depressive than anxious diagnoses.
Because the FDA required manufacturers to prove a drug's efficacy for some biomedical condition, the SSRIs could not be marketed for generalized distress, but only for specific diseases. In contrast to the many particular anxiety disorders of the DSM-III, the unification of depression around the MDD criteria put depression in the best position to encompass the amorphous symptoms of the stress tradition. Given the hostile cultural and regulatory climate surrounding antianxiety drugs when the SSRIs came onto the market in the late 1980s, it made much more marketing sense for manufacturers to promote them as antidepressants than as antianxiety agents.
Anxiety should become a particularly attractive target for trademarked SSRIs. More than a quarter of the population experiences enough symptoms of anxiety disorders to meet the DSM's criteria, making the group of anxiety disorders the most prevalent of any general category of mental health conditions (Kessler et al. 2005). As one marketing report points out,
While the differentiation of the many forms of anxiety in the DSM-III initially enhanced the appeal of the unitary condition of MDD, each form of anxiety now can become a segmented market. For example, in 1999 the FDA approved Paxil for the treatment of social anxiety disorder (SAD) and Zoloft for PTSD; two years later Paxil and Effexor gained approval for the treatment of generalized anxiety disorder (GAD). Old drugs can seem innovative and up-to-date when they are prescribed for new indications. Different brands can target a variety of specific types of anxiety conditions and capture distinct niches. The extraordinary success of GlaxoSmithKline's efforts to promote Paxil as a treatment for SAD indicates the huge potential of anxiety conditions as pharmaceutical targets. A vast advertising campaign blitzed the media shortly after Paxil was approved in 1999 for treating SAD, which previously had been viewed as a rare disorder. Paxil became the largest-selling antidepressant at the time, with sales of $3 billion a year, since consumers now widely recognized anxiety as a reason to seek drug treatment.
The movement from generalized conditions grounded in anxiety to specific disease categories dominated by depression has had major consequences for mental health policy. Because the targets of mental health treatment came to be viewed as specific diseases, the use of drug treatments, particularly antidepressants, soared. Responses to common mental health problems became equated with the prescription of medication at the expense of alternative psychotherapeutic approaches. At the same time, the use of psychological and social options for common mental health problems has substantially declined, despite evidence that they are at least as effective treatments as pharmaceuticals (and that the combination of various therapies can be the most successful of all).
Depressive and anxiety symptoms are widespread among adolescents today, creating a large social problem. However, few previous studies have addressed depression and anxiety among adolescents in Chinese cohorts. The aim of this study was to evaluate the prevalence of and risk factors for depressive and anxiety symptoms among Chinese middle school adolescent students in the post-COVID-19 era. 2ff7e9595c
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