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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)

  • Bravo!

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  • I think we need to take a slightly more nuanced approach to 'depression' insofar as distinguishing this from Sh't Life Syndrome where these agents are used inappropriately oft-times because 'something must be done' irrespective of how futile it may be.I also think the Monoamine Theory of depression is less than comprehensive and political factors also act to tie the hands of psychiatrists with respect to actually having a broader range of tools which have many indicators of efficacy to at least make them worthy of investigating again. Some brave individuals including the team at UCL are making small but important steps into this with their work on psilocybin and dimethyltryptamine and I hope the politicians keep their bloody noses out of their work. The arylcyclohexylamines such as ketamine have also shown great promise which has recently hit the mainstream press; this is not new knowledge but simply knowledge which has been revived.We have many tools which could be of use but politics typically sullies matters and many people are the poorer for this, and this includes those with sh#t lives.

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  • I work in hospital psychiatry, and part of our training is antipsychiatry, for example Thomas Szasz who wrote The Myth of Mental Illness. I guess we should always balance the pros and cons of prescribing antidepressants.

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  • Very brave.

    I agree with most, but not all, of what you say.

    Speaking from both personal and professional experience, I think asking about anhedonia is one of the most discriminating features. When people genuinely don't enjoy anything they do, at any time, they are likely to be moderately depressed.

    The only thing which conflicts with this is the recent database of treatments which was attached to the NICE guidance on multi-morbidity. It quotes the NNT a relapse of depression as only 4 per year.

    But at the end of the day, pharmaceutical companies are making big bucks out of this so we are unlikely to see a clear picture if research is industry funded.

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  • Brilliant article, and so true sadly

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  • I agree that there is now with over-medicalisation of adjustment disorders. As a practising GP, it is hard to access timely high quality CBT. Des's columns are provocative and they make important points about the direction of modern medicine and public health. There is big need for CBT access.

    However I cannot agree that antidepressants should not be prescribed in primary care. If used judiciously for selected patients, they can be transformative. Shabi Nabi's point about (core symptom) anhedonia is key. Risk assessment for suicide is also necessary. Let us not throw the 'baby out with the bathwater'.Where evidence may be conflicted, I would would urge GPs to be safe and consider using guidance in BNF or at CKS/NICE

    What do others think?

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  • Excellent and brave article, well researched. Worth reading Cracked by James Davies. The use of Antideps in primary care is currently encouraged by all and sundry, patients expect them specialists want you to start them. Of course the side effects of GI irritation and psychologic side effects are lack of real usefulness is glossed over.

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  • This article totally falls into the very unhelpful polarised debate of counselling good drugs bad and stigmatises psychiatry and psychiatrists as drug pushers for the pharmaceutical industry.
    It amazes me that we don't have similar debates about other medications prescribed for potential medical outcomes with much higher numbers needed to treat and just as many or worse side effects.
    Surely it's what works for the patient. The more severe the depression the better effect you get from an antidepressant. GPs don't have the time needed to explore symptoms and circumstances of a person let alone the resources to do anything about them and thus this feeling of helplessness is easily deflected as anger onto psychiatry.
    There is a huge huge gap in provision between primary and secondary care for mental health issues. This tired old dialogue continues to perpetuate suspicion of mental health services and leads to poor adherence. Thanks.

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  • I'm willing to accept that SSRIs are placebos, but frankly if 50mg sertraline for 6 months does the trick for large numbers of patients, is that really so wrong? Many patients tell me counselling was no help at all, and the wait for meaningful CBT is nearly a year. (And CAMHS is virtually non existent any way, they reject the majority of GP referrals). Since there is nowhere near enough money to put into expanding expensive counselling services, why take away the only weapon we have left? Patients won't say "fair enough guv", they will demand alternative drugs.........benzos, hypnotics, pregabalin, antipsychotics.......is this really better than a subtherapeutic dose of cheap generic relatively safe SSRI? Secondary care would be crushed under the weight if we could not prescribe in GP land.
    I'm afraid this idealistic and bold suggestion, even with solid research backing it up, is too late. The SSRI horse has bolted.

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  • @David Banner

    Well said. A prescription for an SSRI is a pragmatic approach to a set of problems which rarely have obvious solutions.

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