Anxiety and depression are the most prevalent mental disorders worldwide (1). Approximately one in five persons experience one of both disorders during their lifetime, and these numbers continuously increase over time (2, 3). There is ample research that focuses on either disorder, yet social scientists rarely examine their interrelatedness empirically (4, 5). This begs the question of whether anxiety disorder (AD) and depressive disorder (DD) are different sides of the same coin?
Indeed, in sociology, the similarity between AD and DD is often emphasized, referring to their shared risk factors and social outcomes (3, 6). Social constructionists even claim that distinctions between mental disorders are a consequence of medicalization, which is defined as the process by which a non-medical problem, behavior, or human condition is defined and/or treated as a medical problem (7). Mental disorders could indeed be framed as the “medicalization of deviance” (8), perhaps even as “transforming normality into pathology” (9). Yet, the way mental disorders like AD and DD are medicalized, changed drastically throughout the years, resulting in contrasting diagnoses and treatment methods (7). Consequently, this has led to very different outcomes for the numerous individuals that have been treated with either (or both) disorders and how society perceives these disorders and treatment methods (4, 10, 11). Only, to our knowledge, no empirical research exists that scrutinizes how this process affected changes in treatment methods over time and how this differs between persons with feelings of anxiety versus feelings of depression.
Our research aims to address this gap by investigating how the medicalization of feelings of anxiety and depression evolved in recent years, specifically focusing on psychotropic drugs consumption. Traditionally, anxiety feelings have been treated with tranquilizing psychotropic drugs, such as benzodiazepines, which could broadly be classified under the term psycholeptics (12). On the other hand, feelings of depression are generally treated with stimulants such as selective serotonin reuptake inhibitors (SSRIs), classified as psychoanaleptics (13). In the current paper, we use this distinction as an ideal-typical dichotomy, allowing us to gauge the foundations of the medicalization processes of both disorders.
In addition, we assess whether a social gradient might mediate these suggested shifts. This second aim is guided by the great body of literature that deals with inequalities in both the access to and use of mental healthcare (14). Our study will use education level as a proxy for this social gradient, as education is identified as one of the most fundamental causes of social disparities in healthcare use (15), with those who are higher educated generally taking on a more active role in the treatment process (16).
In doing so, we will make use of the second (2004), third (2008), and fourth (2013) waves of the Belgian nationally representative Health Interview Survey (HIS), executed via repeated cross-sections. This paper ascertains (i) whether shifts in treatment for feelings of anxiety and depression have occurred during the observed period while focusing on both types of psychotropic drugs use, (ii) whether these suggested shifts are comparable, and (iii) whether a social gradient might mediate these shifts
The medicalization of feelings of anxiety and depression
In the literature, anxiety disorder (AD) is generally defined as having an excessive reaction to a future threat (17). In turn, Depression disorder (DD) is defined as having an excessive manifestation of sadness (18). Nevertheless, “excessiveness” is not defined at all, leaving AD or DD diagnoses subject to individual interpretation, often in combination with diagnostic tools, such as elaborate symptom checklists (19). Importantly, moreover, is that these definitions and symptoms have changed dramatically throughout the last decades (4, 20), with striking shifts that align with the first and second generations of medicalization (7). This has had an undeniable impact on the way these disorders are perceived (by society, clinicians, or patients), and is directly linked to their diagnoses, prevalence, and treatment (19).
A quintessential example of this are the shifts in the definition of AD and DD by the American Psychological Association (APA), which had (and still has) an eminent influence on the medicalization of feelings of anxiety and depression in most high-income countries, including Belgium. Over the last decades, the APA systematically widened its sphere of influence by monopolizing mental disorders, deciding which feelings should be classified as disorders and which should not (9, 21). Over the years, the APA systematically increased the number of ADs, framing a growing number of personal characteristics as AD pathologies (e.g., shyness becoming social phobia) (22). In turn, while DD was still quite obscure before the 1980s (with only a few persons qualifying for its severe symptoms and diagnostic criteria), this changed with the publication of the third diagnostic and statistical manual (DSM-III): DD were increasingly becoming more generalized under the umbrella term of ‘major depressive disorder’ (MDD). For instance, the DSM-V discarded the contested ‘bereavement clause’, which excluded “normal” feelings of sadness from depression, induced by, for example, grieving a close death, thereby inevitably causing diagnoses (and consequently the use of psychoanaleptics, such as antidepressants) to rise significantly (23). In succession to AD, DD consequently became “psychiatry’s most marketable diagnosis” (24).
These shifts in the delineation and definition of AD and DD went hand in hand with shifts in the prescription and consumption of psychotropic drugs. Stimulated by the rapid development of these drugs during the last century, the dominant idea grew to cure mental disorders with medications. Importantly, however, is these new treatment methods often merely suppressed symptoms, rather than eliminating their cause (20, 21). Even so, these methods were continuously promoted by professional organizations and the pharma industry, first to clinicians, and then to the public, giving rise to the age of psychotropics (24).
However, while developments in psychoanaleptic drugs treatment initially showed promise, psycholeptics were increasingly perceived dangerous due to their addictive properties (25, 26). As a result; in recent years, psychoanaleptics have become the go-to remedy for both feelings of anxiety and depression, and an increasingly wider array of other mental disorders as well (25, 26). Aggressively pushed forward by the APA, the use of psychoanaleptics has increased steadily for all ages, genders, and ethnic-racial groups (25, 26). There is an increasing overlap in how both AD and DD are treated, causing the conceptual lines between them to blur. Or, as Ehrenberg (27) notes: “Everything becomes depression, because antidepressants act on everything”.
Within Belgium, where this study is situated, mental healthcare policy largely follows the APA’s DSM recommendations for diagnoses and treatment options (see e.g. 28). As such, it is estimated that nearly one-tenth of the adult Belgian population used an antidepressant in the past thirty days (29). In turn, while still having a higher consumption rate in Belgium (29), the use of psycholeptics decreased or at least stabilized, especially for long-term use (30).
The aforementioned shifts in the medicalization of feelings of anxiety and depression happened in an area of the emergence of managed care systems. Elaborate insurance schemes typically characterize these systems, mixing both basic (public) plans with more privatized “extra” plans for those who can afford it (31). At best, basic security is offered to those most in need (as is the case in Belgium, see e.g. 32), yet in more privatized national healthcare systems, such as the USA, this is less evident (33). Industrialized healthcare systems are, however, hypothesized to converge to one another, i.e. leading privatized systems to become more centralized and vice versa (e.g. 34). The same is true for Belgium. What types of treatment are refundable is constantly evaluated by government subsidiaries, such as the National Institute for Health and Disability Insurance (NIHDI). For example, in 2013, the Belgian Psychotropics Experts Platform (BelPEP) was founded as a result of a worrisome publication concerning the (over)use of psychotropic drugs within the Belgian population (35). BelPEP (35) advised the NIHDI to restrict the use of these kinds of psychotropic drugs, particularly psycholeptics. This led to the formal Royal Resolution of September 6, 2017, significantly tightening prescription regulation, e.g., to individuals with a history of addiction.
The social gradient within medicalization
Added to the already present social gradient within the prevalence of disorders such as AD and DD, inequalities also exist in the medicalization of both disorders, highlighting its complexity and diversity (e.g. 36). During the first generation of medicalization, these inequalities were largely (re)produced by clinicians, for instance, by choosing who they ultimately prescribe certain medications or treatments to (37). Moreover, it is argued that at least some prevalence disparities, such as individuals with a more precarious socioeconomic position being more likely to have feelings of anxiety and depression (see e.g. 38), are partially mediated by this process, whereas individuals with higher SES might simply enjoy better healthcare on average (14, 39).
The nature of this stratification changed during the second generation of medicalization. With healthcare becoming more an individual responsibility, patients became more active in their personal healthcare management. In the previous century, treatment with psycholeptic drugs was highly promoted to the middle and upper classes, leaving the lower classes to miss out (4, 7). However, when the perception towards these medications shifted and the upper class abandoned them, they only just started to become available for the lower classes, leaving them to become their new primary users (4).
Educational level seems of particular importance in this context. While persons with lower educational level are generally more at risk of anxiety feelings (40) and depressive feelings (41), it also influences health care behavior in patients. Persons with a higher educational level are generally less likely to consume psychotropic drugs (42) and take on a more active role as a patient (7, 16). Furthermore, they tend to be more informed concerning different treatment options, which helps them gain access to newer forms of treatment (16). Persons with lower education are, however, more likely to consume psycholeptics such as benzodiazepines (42). Additionally, persons with higher education increasingly opt for alternative medicine, with a great emphasis on preventative health behavior (43). This suggests there is an ongoing trend of demedicalization and shifts in help-seeking behavior, especially in those that are higher educated (16, 43).
The aim of this study is to describe how the medicalization of feelings of anxiety and depression may have shifted throughout the observed period. Based on the literature, we expect that a shift from psycholeptic to psychoanaleptic drugs will have occurred (hypothesis 1), and that this shift was most outspoken for persons having more anxiety feelings with them being less likely to consume psycholeptic drugs, in favor of psychoanaleptic drugs (hypothesis 2). Lastly, we expect that persons with a higher educational level will be less likely to consume either type of psychotropic drugs compared to those with lower education (hypothesis 3). This would fit in with current demedicalization trends, where we expect a general downward trend in either type of psychotropic drugs consumption to be highest in those with higher educational levels (hypothesis 3b).