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At the heart of general practice since 1960

Is it time to slash psychoactive drug prescribing?

Dr Des Spence argues for a 50% cut in prescribing but Dr Michael Banna says that we need to address mental health stigma first

YES

GPs are expected to defer to specialists, whose slick presentations of pristine research show us where we are going all wrong. But in the dirty real world, this evidence sinks into the quagmire of uncertainty that is general practice. This is a particular problem with psychoactive medication, with specialists accusing GPs of ‘under-diagnosis’ and ‘under-treatment’. So we have witnessed a doubling and even a tripling of the use of opioids, sedatives, antidepressants and gabapentinoids within a decade.¹ But after the ‘experts’ are gone, GPs are knee deep in the unforeseen and disastrous consequences. Supposedly concrete evidence is now being exposed as flimsy, prefabricated pharma research junk.²

For example, the definition that ‘pain is what the patient says it is’ is impossibly broad and wrongly marks out large swathes of the population for potential treatment with opioids. But opioids bring escalating dependence, are ineffective over time and are causing an epidemic of prescription drug deaths internationally.4 As for benzodiazepines, all GPs know the decades of harm they have done. Research now even links them to dementia.5

The gabapentinoids are a disaster in waiting, with a two- to three-fold increase in prescribing over the past five years. These are widely abused and also implicated in drug deaths.6 In the US, gabapentinoids are being rescheduled as controlled drugs.7

As for antidepressants, these have been shown to be little better than placebo in GP populations.8,9,10 With scant evidence of long-term benefits, they are associated with withdrawal syndromes and patients struggle to stop them.11,12

Antidepressants also medicalise normality, create doctor dependence and deny people the chance to develop their own coping strategies. And why weren’t intuitive and effective talk-based interventions promoted in the 1990s rather than medication? All these psychoactive medications are doing real and lasting harm.

Lastly, how much of our time is wasted reviewing psychoactive prescriptions, fretting about diversion and dependence? It’s time to ignore those Big Pharma mafioso medical experts with their financial conflicts of interest. Less medicine is almost always better medicine. We could (and should) halve the levels of prescribing. General practice needs to seize this agenda.

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

 

NO

Psychoactive drugs make up a massive range of medications that are used successfully for a wide variety of conditions. Restricting them could be hugely detrimental.

Rather than trying to avoid or cut back on certain treatments, we should simply ensure we use them appropriately. I am totally against frivolous over-medication of any patient, but attempting to avoid prescribing psychoactive drugs because we sometimes overuse them puts us on a slippery slope to denying patients treatment they will benefit from.

If we are using these medications inappropriately, we should educate ourselves and change our practice, but we should not need any arbitrary constraints.

One of the biggest obstacles we face in the treatment of mental health problems is stigma. While patients are happy to accept that their blood pressure needs controlling, being medicated for mental health problems can often be seen as a sign of failure. Any attempt to reduce our prescribing of these drugs risks appearing to be an endorsement of this damaging view.

It would be more helpful to find a way to spend more time discussing management choices with patients. For example, when treating mood disorders, there seems to be an assumption that GPs just ‘hand out antidepressants’ rather than considering other diagnoses and options. Longer appointments would give doctors and patients time to discuss and agree on a management plan that could involve more than medication - as well as help to counter the suggestion that GPs are simply thrusting a green slip at the patient and shoving them out of the door.

Increased availability of talking therapies, in-house mental health practitioners and multidisciplinary pain clinics might also reduce reliance on psychoactive prescribing. This would of course be hugely dependent on the commissioning of local services, but where education is concerned, we can all improve our skills as part of our continuing professional development.

At the end of the day, though, some patients want - and need - medication.

No drug should ever be prescribed without clinical justification, but neither should there be a blanket reduction of a whole range of drugs that are helping many people.

Dr Michael Banna is a GP in Bognor Regis, West Sussex

 

 

References

1 NHS Health and Social Care Information Centre. Prescriptions dispensed in the community: England.

2 Gotzshe P. Does long-term use of psychiatric drugs cause more harm than good? BMJ 2015; 350.

3 Chou R et al The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention workshop. Ann Intern Med. 2015;162:276-86.

4 Lyapustina T. The prescription opioid addiction and abuse epidemic: how it happened and what we can do about it. Pharm J, 11 JUN 2015.

5 Billioti de Gage S. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 2014;349.

6 Public Health England. Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. December 2014.

7 Spence D. Bad medicine: gabapentin and pregabalin. BMJ 2013; 347.

8 Fournier JC, DeRubeis RJ, Hollon SD et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47-53

9 Kirsch I, Deacon BJ, Huedo-Medina TB et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med20085:e45.

10 Arroll B, Elley CR, Fishman T et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009;3:CD007954.

11 Geddes JR, Carney SM, Davies C et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 2003;361:653-61

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

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Readers' comments (15)

  • A well written, referenced argument vs an anecdotal fairytale... I know which I prefer!

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  • This is presented as an argument that isn't one really where the gist of both of these is: approriate prescribing at therapeutic doses for the shortest time, not medicalising normal distress, providing alternatives to just medication at the primary care level and embedding that at a practice level etc.

    Referrals to mental health services may be as unhelpful as handing out a prescription where normal experiences are turned into issues that you "need" to see a psychologist about. It clogs up the system for those who do really need more intensive psychological intervention

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  • Useful article although putting it in practice remains subjective

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  • Fantastic but short debate. The tide has to turn against SSRI s in particular. There is no evidence that serotonin plays a role in depression - it's only an hypothesis and we have wasted enormous time and money in pretending that they work. We cannot afford to keep doing this. Google "Irving Kirsch" and you'll see what I mean.

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  • New Scientist editorial this week is interesting reading. Neuronal Connective problems eg depression, may need adequate and appropriate medication.

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  • I am an NHS psychiatrist who has worked In Scotland over the last 20 years.

    I fully agree with Dr Spence.

    "Education" of my specialty has been, and sadly continues to be provided most significantly by vested interests.

    If you are in doubt you can have a look at the evidence I have provided the Scottish Parliament: https://holeousia.wordpress.com/about-me/a-sunshine-act-for-scotland/

    In NHS SCotland antipsychotic prescribing, in all ages, is rising year on year.

    Antipsychotic prescribing to our elders has doubled in a handful of years. This may be the result of delirium/dementia "awareness" campaigns and Improvement work nationally.

    1 in 9 of adult Scots are on antidepressants. Many of then stuck on them. Though some expertsd have advised such is "appropriate" treatment. Some have even described prescribing as "conservative"

    Dr Peter J Gordon

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  • sWhat is really needed of for psychiatrists to come out of their cosy offices and actually see patients, then start treating the causes, not the symptoms!
    In my area patients are only ever seen by a nurse, including in a crisis the main aim being to stop the patient being a nuisance.
    Hospital wards are like prisons with locked doors and rattling keys and patients being treated like naughty children. There is no meaningful activities on wards with most of the staff ensconced in the office.

    Imagine a nice summers days and you want to sit outside .. the doors are locked ... no staff available to sit with you, so in sheer frustration you 'blow your top' ... a needled in the backside on carted off to s side room ... and they call that care simply because you wanted some fresh air!

    Mental health needs a revolution, fewer pills, more staff and bucket loads of compassion!

    Mental health care turns unwell folk into junkies.

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  • my PDP is based on examples like below:

    why does a depressed pt end up on queiapine, mirtazepine and sertraline by a psychiatrist and still doesnt feel fine! and on review the medication is titrated up each time.
    rational of using such combination in 80+ old lady.

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  • I suffered from a major depressive episode.I needed antidepressant medication to get me to a point where I could engage in discussing my problems and engage in exercise etc

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  • SSRI + quetiapine + 'sleepers' is standard treatment. Titrate dose upwards until patient is a obese drooling wreck and no longer able to complain of feeling unwell.

    Job well done.

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