Advice for parents on acute RTI
Fears are growing that waiting times for psychological therapies are putting depressed patients at risk. By Nerys Hairon
Martin was in his late 30s. He seemed mildly depressed but no worse than that. His GP had been confident he was doing the responsible thing by avoiding antidepressants and instead placing him on a six-week waiting list for counselling. Two weeks later, the GP received the distressing news that Martin had made a serious attempt to end his life.
Not even the patient himself had expected it. The case was a stark reminder than even the mildest depression can take a turn for the worse in a matter of days.
'Prescribing an SSRI might have made a difference, it might not,' said the GP. 'He had no suicidal ideation at all, and even afterwards he said he had no idea he was going to be like that.'
Yet the dilemmas GPs face when deciding how to treat depressed patients are getting tougher, not easier, as regulatory bodies clamp down on the use of antidepressants.
Latest NICE guidelines advise GPs not to prescribe antidepressants first-line in mild depression, while the European Medicines Agency has provisionally ruled against the use of SSRIs in patients under 18. It is now conducting a European Commission inquiry which could ban their use altogether in younger patients.
But GPs are desperately short of alternatives. The NHS Alliance says that while most PCTs do provide counselling and cognitive behaviour therapy, the services are 'as good as useless' because waiting lists are so long.
NHS Alliance GMS contract lead Dr David Jenner, a GP in Cullompton, Devon, said: 'Giving a referral for something that might happen in three months is not as good as giving a prescription which is likely to work within two to four weeks.'
The Depression Alliance, a charity that supports people with depression, claimed patients were waiting three to six months for counselling and three months for CBT.
And it said waiting times for hospital psychiatrists were already three to six months and were set to grow, at
least for paediatric psychiatrists, as GPs stopped prescribing SSRIs to children.
GPs are warning specialists are already starting to bounce back referrals to GPs as 'inappropriate' as their workload grows.
Professor André Tylee, professor of primary care mental health at King's College London, confirmed the provision of counselling or psychological services was 'woefully limited' in primary care.
He blamed a lack of trained psychologists for many of the problems. But he warned: 'It is often difficult as a GP to personally find the time to deliver non-drug interventions these require more time than the standard consultation.'
Dr Chris Manning, chief executive of Primary Care Mental Health and Education, called for adequate funding for psychological therapies 'without postcoding', saying he knew of only eight or nine enhanced services for depression in the UK.
But he echoed the feelings of many GPs by insisting
psychological therapies were 'complementary therapies but not alternative ones' and warned against a 'witch-hunt' on SSRIs.
'There is plenty of evidence that the two medication and psychological approaches is the best approach,' he said.
RCGP vice-chair Dr Graham Archard, a GP in Christ-church, Dorset, said GPs would have 'little option' but to continue to prescribe antidepressants, since they could be delivered quickly and had a strong evidence base.
He said the alternative was to keep patients waiting for treatments that might not have proven benefit.
'It's difficult to be sure that someone has mild depression instead of mild to moderate,' he added. 'It's not overprescribing because you are potentially preventing suicide.'
But Dr Lizzie Miller, a GP with a special interest in
mental health in Fulham, west London, insisted GPs already had many alternatives to SSRIs for mild depression and that patient expectations needed to be changed. 'I absolutely agree with NICE,' she said. 'There are services like the Samaritans and Mind, as well as local church groups.'
Dr Miller said psychological therapies did have a 'reasonably firm evidence base' and that there needed to be a 'culture shift' to encourage patients to find other solutions.
The patient's name has been changed to protect his identity
Alternatives to antidepressants
Cognitive behaviour therapy
·Challenges negative thought patterns and aims to change destructive behaviour
·Stronger evidence base than other non-medication therapies
·Average waiting time of three months, although a small number of practices have their own therapists
·Focuses on relationships, communication and
·Evidence of efficacy alongside other treatments for depression
·Waiting times of three to six months
·Focuses on past conflicts and reducing feelings of aggression
·Some evidence of effectiveness
·Waiting times of three to six months
Sources: Department of Health and Depression Alliance