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Gold, incentives and meh

We need to stop prescribing antidepressants in primary care

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People say I always write the same articles, and they’re probably right. So here is an old chestnut, on antidepressants. My view is simple. These medications are overprescribed and prescribed for too long.

Now obviously, why should anyone listen to a chav like me, rather than some illustrious Oxbridge professor of psychiatry, asserting that depression is underdiagnosed and undertreated? And when the psychiatric tanks are about to roll into the quagmire of modern child mental health in a campaign to improve the wellbeing of our children and defeat depression.[1] Surely this a good thing? What sort of idiot could object?

Well I do. The ‘Defeat Depression’ campaign in adults in the 1990s was an unmitigated disaster for society. It led to vast numbers of prescriptions, lifelong treatment and side effects. Antidepressant prescribing rates have since doubled in a decade, to an eye watering 61 million prescriptions in 2015.

This is despite much evidence suggesting antidepressants are completely ineffective.[2,3] Most of the observed ‘benefit’ is merely due to an exaggerated placebo response and even by the most optimistic calculations 85% of patients get no benefit from medication at all.[4,5] And when patients try to and stop, half experience withdrawal with agitation, insomnia and mood swings, which many construe as a return of their low mood.[6] Yet we know that non-drug talking therapy alternatives work better than antidepressants.[7]

The problem is the psychiatric community has used antidepressant medications to validate the ‘chemical imbalance’ model and endorse widespread polypharmacy in other mental health conditions. But this model has limited science to support it, especially in depression.[8] And the definition of depression is equally unscientific and arbitrary. Two weeks of symptoms? Why not eight weeks? Who decided this cut off?

Most people in primary care have reactive depression or adjustment disorders. But challenging this prevailing wisdom of course means I am stigmatising and dismissing mental illness and should be shouted down. But we all suffer mental illness at times, be it anxiety or depression, I know that I certainly have. The issue is how we manage mental illness.

Clearly psychological pain, just like physical pain, has a purpose - it is an evolutionary response. Psychological pain is the catalyst of change, acceptance and moving on. Talking it through, addressing social stresses, changing lifestyle and perhaps ending unhappy relationships is the solution. Antidepressants are not the answer for the vast, vast majority of people. We should aim to normalise, not medicalise.

Of course this will be dismissed as simplistic drivel, as life ‘is more complex than this’. But in my view it isn't, it really is as simple as that. If we want to help sort out adult mental health services, then make access to counselling a top priority. A simple solution would be to cut the standard six session approach to three. Bingo – twice the amount of access! Simple things often do work.

Lastly, good luck sorting out mental health issues in children. As a parent of four, you realise that broad themes in society are usually at the root, with confused and unrealistic expectations messing with their minds. Psychiatry, contrary to popular mythology, has no magic insight or silver bullet to offer. Psychiatry will make it worse with a binary unscientific biological model, with a mantra of medicate, medicate and medicate. It will disrupt and deny the children the opportunity to work things through themselves.

Please can we have renewal of psychiatric and medical thinking, for I get tired of writing the same articles.

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

 

References

1. Barej A. NHS ‘struggling to improve mental health services for young people’. Public Finance; 22 Mar 17

2. Fournier JC et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010; 303: 47-53

3. Kirsch I et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5:e45 

4. Shedden Mora M et al. Lessons learned from placebo groups in antidepressant trials. Philos Trans R Soc Lond B Biol Sci 2011; 366(1572): 1879–1888

5. Arroll B et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009; 3: CD007954

6. Haddad PM, Anderson IM. Recognising and managing antidepressant discontinuation symptoms. Adv Psychiatr Treat 2007; 13: 447–57

7. British Association of Chartered Psychotherapists. Effectiveness of counselling.

8. Lacasse JR, Leo J. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med 2005; 12: e392

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Readers' comments (43)

  • I find that the key is patient selection. Those with prominent biological symptoms respond very well. SSRI can transform a life similar to a knee replacement. Of course overused in a pressurised system. Same as antibiotics.

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  • I'm glad you're not my GP.

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  • I am certain that we all want to prescribe as appropriately as we can.

    To prescribe based on evidence alongside the consideration of the unique context of the person.

    I worry that this is not possible if we have Continuing Medical "Education" based on:

    https://holeousia.com/2017/05/25/continuing-medical-education/

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  • Keep writing articles like this Des! This is the side that we don't hear otherwise why would so many SSRI prescription's be written out?

    I would add it's not just a stark choice between a CBT waiting list and medications.

    -We can inform patients about the benefits on mood from a healthy diet- ref the SMILES study Jan 17 looked at the benefits of the modified meditetanean diet.
    -Exercise 30 % improvement in depression ref RCGP factsheet.
    -Relaxation activities/ mindfulness
    - Support from family and friends (often they've not spoken to anyone apart from the GP )
    - the beneficial effect of talking to the GP who cares about them and whom they can see again.
    -talking therapy when available

    We can give them a choice on this approach or SSRI 's or both . I agree that SSRI's are likely placebo effect in most but some patients gain benefit from this if unmotivated to do the above.

    In my experience patients like the lifestyle approach and taking control rather than being told a drug will fix them.

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  • AlanAlmond

    SSRIs are one of the few meds we prescribe that actually work. The issue is they need to be prescribed appropriately. It seems to me there are a group of Drs who don't believe they do anything. That's not my experience ... but then we see what we want to see in much of life. Not prescribing them at all suggest to me an approach somewhere at the edge of the 'normal distribution' bell curve.

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  • Even if the drugs do work, 60 million a scrips per year should be a wake-up call. This approximates to an average of one scrip for every adult - an incredible number.
    Medicalising unhappiness does not help unhappy people, but does create a huge workload for a service struggling to cope.

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  • Thank you so much for having the courage to point out that actually the Emperor may have no clothes.True endogenous depression is a rare and debilitating illness where drugs and even ECT may well be needed. The rest is just the slings and arrows of outrageous fortune.Giving a patient a pill to get them out of the room diminishes us and destroys their self resolve.

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  • AlanAlmond

    What does 60 million scripts a year mean? how many actuall people does that represent? that's the important issue. A single prescription might only last for 2 weeks, getting hung up on the total number is meaningless and almost deliberately confusing the issue. This is a wonderful example of the illusion of online social media debate. Everyone with the same opinion hangs out agreeing with each other and suddenly you get the feeling this is the consensus view ...despite glaring evidence to the contrary. If we're all kinda coming to the view SSRIs are pointless and somehow 'immoral' how come so many of our collegues are prescribing them? Could it possibly be most don't agree?

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  • Vinci Ho

    Personally love this debate.
    Truth only surfaces with constant ongoing debate.
    I don't know about you but I may be one of the few busy GPs who still use PHQ9 as well as GAD7 before initiating any SSRI these days.Yes , it was once in QOF and dropped later . Would not normally commence antidepressant if PHQ9

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  • Vinci Ho

    is less than 15. Refer all commenced on SSRI to talking therapy no matter how long is the waiting time.
    Stop initiating any paroxetine/Seroxat over 10 years.
    Extremely careful in age 16-18 and would not anything other than fluoxetine.
    Children must be referred no matter how poor the local secondary care service is .
    Does it work? It had worked in many of my patients alongside with talking therapy and behavioural modifications.
    When does it not work ? Complex psycho-social differential diagnoses co-existing (identified or non-identified at the time of commencing ).
    Serious doubts about high dose SSRI efficacy in OCD.
    Never work in certain personality traits
    My own opinion ....,,

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