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15 years of mixed messages

By Nerys Hairon

Of all the difficulties GPs face over the state of depression services, the dilemma it raises on use of antidepressants is one of the most frustrating.

The confusion over when drugs are appropriate ­ given the long waits for psychological therapies ­ is the legacy of well over a decade of mixed messages and conflicting advice.

Nowadays, GPs regularly attract criticism for prescribing antidepressants too often, but it was different in the early 1990s, when the emphasis was on the effectiveness of drug therapy.

Professor Christopher Dowrick, professor of primary medical care at the University of Liverpool and a GP in the city, says: 'As GPs, we feel obliged to do something when faced with patients' distress. Prescribing an antidepressant is often all we feel competent to do ­ even though we're aware it may at best be only part of the answer.'

Dr Robert Morley, executive secretary of Birmingham LMC, adds: 'We get damned if we do and damned if we don't. We just have to develop a thick skin.'

Depression was forced to the top of GPs' agendas by 1992's Defeat Depression campaign, launched by the Royal College of Psychiatrists in association with the RCGP.

The campaign's main aim was to educate doctors in recognising and managing depression, but its effect was to contribute to an explosion in anti- depressant use. New prescriptions more than doubled between 1990 and 1995, according to the Government's now defunct Clinical Standards Advisory Group.

But in spite of this, a report by the group in 2000 criticised GPs for using antidepressants at below target doses: 'The usual dose of a tricyclic antidepressant in primary care is well below the level guidelines recommend.'

Since then, antidepressant prescribing has continued to soar, by five-fold for adults from 1990 to 2005, figures from CompuFile show (see below).

Dr David Kessler, a senior research fellow in community-based medicine at the University of Bristol who has researched the economics of depression treatment, attributes the rise to 'multiple' factors, including the increasing popularity of SSRIs after concerns over tricyclics.

'It has multiple causation: the rise and rise of the SSRI and the perceived attractiveness of this new drug ­ and it was also part of a broader change in the social acceptability of emotional disorder,' he says.

The Government's mental health tsar, Professor Louis Appleby, understands GP frustration: 'It's not surprising GPs feel they have to use antidepressants because for quite a long time the message was they were missing depression too much. The available treatments then were drugs.'

But the new millennium brought a sea change in attitudes to SSRI prescribing.

In May 2003 the Medicines and Healthcare Products Regulatory Agency announced a safety review of SSRIs, prompted by concerns over withdrawal reactions and suicidal feelings.

This culminated in advice that only fluoxetine should be used in under-18s, antidepressants should be used at the lowest possible dose and warnings should be strengthened on the risk of withdrawal reactions.

But GPs feel frustrated that the warnings over SSRIs and NICE guidance recommending talking therapies first-line for mild depression have left them in an impossible position.

Dr Nigel Watson, chief executive of Wessex LMCs and a GP in the New Forest, Hampshire, says: 'We continue to use SSRIs ­ what are the alternatives? No counselling, psychology, or CBT.'

Dr Russell Walshaw, chief executive of Northern Lincolnshire and East Yorkshire LMCs, is annoyed GPs have become scapegoats. 'The people who make that criticism have no idea about the pressures GPs face or the clinical problems these patients bring,' he says.

But Dr Steven Harris, who has a CBT clinic in his practice in Crouch End, north London, argues GP must shoulder some of the blame. 'I think they are fairly criticised ­ 90 per cent of patients on SSRIs don't need them. Prescribing an SSRI is often the easy way out but it doesn't do the patient any good.'

Dr Watson sums up the feelings of many GPs: 'I feel fed up more than frustrated ­ we need a decent mental health service.'

nhairon@cmpinformation.com

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