Over-diagnosed and over-treated: a survey of Australian public attitudes towards the acceptability of drug treatment for depression and ADHD

Over the last decade the use of psychotropic medications to treat common mental health problems has increased in Australia. In particular, increases in prescribing rates for anti-depressants and stimulants (typically used in the treatment of Attention Deficit Hyperactivity Disorder) were among the highest for all psychotropic drugs. A recent overview of Australian prescribing trends showed that prescribing rates rose 95% for antidepressants and 72% for ADHD drugs between 2000 and 2011 [1].

While it is clear that doctors are prescribing more psychotropic drugs, we know less about people’s attitudes towards drug treatment. Attitudes towards psychotropic drugs are an important part of the public’s “mental health literacy” [2, 3] that may influence willingness to start using these drugs and continue to use them. The overall upward trend in the prescribing of psychotropic medications has been attributed in part to greater public awareness of mental illness (which may indicate increased treatment seeking on the part of patients) and a growing acceptance of psychotropic medications as an acceptable method of treatment for mental disorders [1]. Understanding public attitudes towards drug treatment is therefore an important part of understanding prescribing trends.

Public attitudes towards the use of anti-depressants have gradually become more favourable in Australia [4, 5]. In 2011 we surveyed 1265 members of the Queensland public (as part of the Queensland Social Survey; QSS) finding that most people (55%) believed it was acceptable to use prescription drugs to treat depression; however, around 15% disagreed outright and almost 30% were unsure or neutral, indicating that there is considerable room for full acceptance of anti-depressants [6]. The two-thirds of participants had either been treated for depression with prescription drugs or knew someone who had, were more likely to view drug treatment as acceptable.

There is good evidence that public attitudes towards drug treatment are not uniform across mental disorders [7]. Our 2011 survey found that attitudes towards the use of stimulants to treat ADHD were sharply divided. The acceptability of drug treatment for ADHD was much lower than for depression (35%) and an almost equal number disagreed outright with such treatment [6]. While there is evidence that parents of children with ADHD are more likely to be accepting of stimulant treatment [8], other studies with Australian parents have found that those whose child had been diagnosed with ADHD are more likely to think that too many children are medicated for ADHD and two-thirds also thought that ADHD was over-diagnosed [9].

Most participants (60.9%) said that it was acceptable to use prescription drugs to treat depression; only 17.5% expressed outright disagreement. In contrast, attitudes towards the use of prescription drugs to treat ADHD were much less positive with around the same proportion saying it was acceptable (42.1%) as unacceptable (38.2%). For both depression and ADHD, almost one-in-five participants answered “Don’t Know” (21.6% for depression and 19.6% for ADHD).

Prescriptions for anti-depressants and stimulants in Australia have increased at a higher rate than almost all other psychotropic medications over the last decade [1, 18, 19]. However, there are ongoing concerns about the extent to which this increased prescribing is accepted by the public, has led to better health outcomes, or is symptomatic of over-diagnosis of mental disorders [12].

This study found that drug treatment for depression is acceptable to most members of the public (approx. 60%), although almost 40% disagreed or were unsure. This result echoes our 2011 findings (see Table 7) [6]. In Australia and the US, public views about the use of anti-depressants have become more positive since the 1990s [4, 7]. In terms of overall support, some surveys suggest a higher level of endorsement for anti-depressants in the treatment of depression among members of the US public compared to the participants in our survey [7]. Drug treatment for depression was regarded as much more acceptable than drug treatment for ADHD. Overall, members of the public were ambivalent about the acceptability of using prescription stimulants to treat ADHD, and only 42% agreed that drug treatment is acceptable for ADHD. This is in line with our 2011 findings and with US surveys showing that a minority of members of the public would choose stimulant medication for a child, and most would prefer behavioural interventions [20, 21].

Our exploration of attitudes towards over-diagnosis yielded results that health care professionals may find concerning – that is, most participants believed that depression and ADHD are over-diagnosed in the first place. In particular, around 78% of participants said that too many children are diagnosed with ADHD when they don’t actually have the disorder. And despite most participants saying that drug treatment for depression is acceptable, nearly 58% said that too many people are diagnosed with depression when they don’t really have it. Importantly, people who thought that depression or ADHD were over-diagnosed were less likely to think that it is acceptable to use prescription drugs to treat these disorders. This raises the prospect that scepticism about drug treatment may be partly based on scepticism about the appropriateness of the diagnosis. Some members of the public who believe that depression and ADHD are too readily diagnosed may be reluctant to seek help from a health care provider even when they (or their children) need it. This may be for a number of reasons including concerns about unnecessary drug treatment and fear of being stigmatised by having a mental health problem. In such cases, perceptions about over-diagnosis and over-treatment could in fact result in some people in genuine need for help going untreated. One other potential implication is that members of the public who do receive a diagnosis of depression or ADHD may be more reluctant to initiate or continue drug treatments if they believe these conditions are typically over-diagnosed and over-medicated. This may be a barrier to effective treatment of these conditions given that drug treatment is often recommended as a first line response. It may be worthwhile for future research to explore how perceptions about diagnosis and treatment influence actual treatment seeking behaviour. For ADHD especially, it would be useful for future studies to explore in greater detail how attitudes towards stimulant prescribing are related to attitudes towards the diagnosis of ADHD, and to the use of stimulant medication. Parents of a child with ADHD may have concerns about the side-effects of stimulant treatment however these concerns may be amplified if they harbour doubts about the proper diagnosis of ADHD.

Members of the Australian public in this study showed high levels of familiarity with drug treatment both conditions – around 67% of participants had either been treated for depression with prescription drugs or personally knew someone who had (65.4% in 2011). Approximately 35% knew someone who had been treated for ADHD with stimulants (28.7% in 2011). Our exploration of other factors predicting positive attitudes towards the acceptability of drug treatment yielded slightly different results to 2011. Knowing someone who had been treated for depression with prescription drugs (or having been treated oneself) was not a significant predictor of positive attitudes towards the acceptability of drug treatment for depression – unlike our 2011 survey. While our 2013 results showed a clear trend towards familiarity being a predictor, it did not reach statistical significance. Other studies with members of the Australian public have suggested that familiarity may be associated with more favourable attitudes towards drug treatment. For example there is evidence that Australians who know someone with depression are less likely to think anti-depressants are harmful [22]. Studies in other countries have found similar results [23]. For ADHD, familiarity was a significant predictor of more positive attitudes towards the acceptability of drug treatment in the current study – the 2011 analysis did not reach significance. This is again an area that well designed qualitative studies could help to elucidate the nature of the relationship between these variables. While familiarity may lend a greater insight into the potential benefits of drug treatment, those who personally know a child treated for ADHD with prescription drugs are also likely to be acutely aware of any negative side-effects.

Although age was not a significant predictor of attitudes towards over-diagnosis, older people were much less likely to say that drug treatment for depression or ADHD is acceptable. This finding warrants further exploration given that older people were over-represented in this sample and participants over 55 years of age were more likely to answer “don’t know”. Compared to all other age categories, those aged 18–34 were far less likely to answer “don’t know”.

Attitudinal surveys can provide a useful snapshot of the public viewpoints. The usefulness and robustness of their findings can be increased if they are repeated. Although there has been an increase in the prescription of drugs to treat depression and ADHD, the findings from the 2013 QSS and 2011 QSS indicate that there is still considerable scope for convincing many members of the public that drug treatment is acceptable or warranted. Addressing the belief that these disorders are over-diagnosed appears to be one part of this. This survey could be conducted again in the future to essentially track attitudes towards these issues over time and further elucidate the factors that influence attitudes. The major limitation of using the sample described in this study is that younger people are under-represented. While this is not unusual for CATI surveys with the general community, it does mean that it would be prudent not to overgeneralise these findings. Under representation of younger people often occurs in CATI surveys that source landline phones only, and dual frame (landline and mobile) surveys may improve the representativeness of future surveys. Nevertheless the survey tool could easily be used with other representative cohorts for direct comparisons or extended to explore other domains relevant to public attitudes towards the acceptability of drug treatment (as we did in the 2013 survey by extending the analyses to explore “over-diagnosis”). This would potentially improve the explanatory power of the survey tool by taking into account a larger number of variables that inform attitudes. The survey could also be adapted to investigate attitudes towards the acceptability of drug treatment for other common mental illnesses such as anxiety and various substance use disorders. This would provide a broader understanding of the spectrum of public attitudes towards pharmacological drug treatment. Elsewhere, we have used a variation of this survey to explore attitudes towards the acceptability of healthy people using prescription drugs for “cognitive enhancement” [24].