Salt Lake City -- Doctors here have for years talked about the widespread use of antidepressants in the state. But there was no hard evidence until a national study that tracked drug prescriptions came to an unexpected conclusion:
Antidepressant drugs are prescribed in Utah more often than in any other state, at a rate nearly twice the national average.
Utah's high usage was cited by one of the study's authors as the most surprising finding to emerge from the data. The study was released last summer and updated in January.
Other states with high antidepressant use were Maine and Oregon. Utah's rate of antidepressant use was twice the rate of California and nearly three times the rates in New York and New Jersey, the study showed.
Few here question the veracity of the study, which was a tabulation of prescription orders, said Dr. Curtis Canning, president of the Utah Psychiatric Assn. But trying to understand the "why" has puzzled many, he said.
"The one true answer is we don't know," said Canning, who has a private practice in Logan. "I have some hunches.
"In Mormondom, there is a social expectation--particularly among the females--to put on a mask, say 'Yes' to everything that comes at her and hide the misery and pain. I call it the 'Mother of Zion' syndrome. You are supposed to be perfect because Mrs. Smith across the street can do it and she has three more kids than you and her hair is always in place. I think the cultural issue is very real. There is the expectation that you should be happy, and if you're not happy, you're failing."
The study did not break down drug use by sex. But according to statistics from the National Institute of Mental Health, about twice as many women as men suffer from depressive disorders.
Discussion of the issue inevitably falls along Utah's traditional fault lines. Some suggest that Utah's unique Mormon culture--70% of the state's population belongs to the church--requires perfection and the public presentation of a happy face, whatever may be happening privately. The argument goes that women in the Church of Jesus Christ of Latter-day Saints are beset by particular pressures and are not encouraged to acknowledge their struggles.
Helen Wright, 71, of Taylorsville, Utah, has been using various antidepressant drugs for 20 years and says she's never had problems getting prescriptions.
"Look around, you can easily find people who take them. I think it's the cultural environment," said Wright, whose three grown children also take antidepressants. "Most men here would just as soon their wives take pills than bother to delve into the problems, and maybe find out they might have something to do with the problems."
Not so, says Fred M. Riley, commissioner of LDS Family Services. The church maintains 10 offices in Utah staffed with licensed counselors. Riley said he has heard the various explanations of the study but he dismisses suggestions that the Mormon religion imposes any expectation of perfection.
"The fact that the church has established family services shows they care about the emotional side of members," Riley said. "In fact, the LDS population is more open to getting help and getting things fixed."
Utah's large families--the biggest in the nation according to the 2000 Census--are often cited as a contributing factor to depression, again, largely among women. Others call the "harried housewife" explanation the stuff of urban legend.
"The question I would raise is whether there is any evidence that a high level of social demand predicts depression," said Amanda Barusch, a professor in the graduate school of social work at the University of Utah. "Who says that having six kids will make you depressed? There's no evidence in the literature that shows that. Stress is not the same as depression."
The study was conducted by Express Scripts Inc., a St. Louis-based pharmacy benefits management company, which tracked prescriptions of 24 drug types in about 2 million people selected at random from its 48 million members. Those studied were enrolled in privately managed health-care programs, and the information gleaned from the study is intended for use by HMOs. Medicare and Medicaid recipients were not included in the study.
Utah also leads the nation in the use of narcotic painkillers such as codeine and morphine-based drugs, the study found, and is ranked seventh in total prescriptions overall. Kentucky ranked first.
The study was the first national survey that examined regional trends in drug use. The information in the "Prescription Atlas," as the study is called, has made little impact here since its publication.
No official interviewed in Utah's mental health or substance abuse agencies had much notion as to what the study says about Utah's mental health.
"To be honest with you, I don't have a clue," said Randy Bachman, director of the Utah Division of Mental Health. Bachman was not in his current job when the study was released. While the results speak for themselves, he added, interpreting why antidepressants are in high use is a thorny matter.
State officials say the study's results could indicate that this is an enlightened society in which depression and mental illness are destigmatized. In such a social climate, they say, more people are willing to seek help and, eventually, are prescribed drugs.
"That's certainly a plausible explanation," said Emily Cox of Express Scripts, one of the five authors of the study. "There's a lot of inferences being drawn from this. We can't say if there is a higher probability for depression or depressive symptoms. You may have a population that seeks care for less severe symptoms. You may have a medical community that prescribes more readily."
Cindy Mann, who lives in Logan, said after 15 years of taking antidepressants and not feeling better, she finally quit in July. Today she encourages others to do likewise, but she's pessimistic.
"It's like Happy Valley here," she said, describing the Salt Lake Valley. "It's a scary place sometimes. People don't talk about their problems. Everything is always rosy. That's how we got ourselves into this mess--we're good at ignoring things."