In the latest in our series, GP and mental health lead Dr Peter Bagshaw debunks some common myths and explains some surprising facts about depression
MYTHS
Myth 1. Antidepressants are more effective than talking therapies
In fact, studies have shown no difference in effectiveness or drop-out rates between antidepressants and cognitive behavioural therapy (CBT) for depressed adults, and NICE guidelines on depression recommend non-drug therapy, particularly for less severe depression, as first line therapy because it is less intrusive and more cost-effective than medication. Whilst this mainly includes CBT and related talking therapies, guided self-help and exercise have also been shown to be equally effective as medication in treating depression.
Myth 2. Serotonin levels are reduced in depression
This has been the accepted wisdom, and underpins the rationale for SSRIs. However, a large scale review of all the evidence concluded that ‘the main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations’. Indeed, it went further, stating that ‘some evidence was consistent with the possibility that long-term antidepressant use reduces serotonin concentration’.
Myth 3. Talking therapies aren’t as useful in older people
In fact, the opposite is true. The proportion of people aged over 65 referred to talking therapies is lower than the proportion in the general population, despite the incidence of depression being higher in older people (15% higher than in under 65s, doubled if the person is in a care home). Indeed, only around 5% of talking therapies referrals are from the over 65 age group, despite them making up nearly a fifth of the UK population. However, data from NHS Talking Therapies (formerly IAPT) has shown a greater proportion of older adults completed treatment and showed reliable recovery (56% compared with 42% of working age adults). Of note, antidepressants are also more risky in this group, and should be used with great caution – the edict ‘Start low, and go slow’ is advisable, but there appears to be an increased risk of falls and cardiovascular events with all antidepressants.
4. Electroconvulsive therapy (ECT) has no place in the treatment of depression
ECT’s mode of action is still not well understood, and is considered by many to be a barbaric treatment which should be consigned to the dustbin of history. However, it can work in treatment-resistant depression (TRD) where other interventions fail, and can sometimes be life-saving, so is still recommended by NICE in certain situations. Memory loss following treatment is common, so other less invasive procedures which stimulate the brain have been developed. Transcranial magnetic stimulation and vagal nerve stimulation have been shown to be effective and are NICE-approved; not yet approved, but with some evidence of effectiveness is direct current stimulation which can be used at home.
Myth 5. Internet-based CBT (iCBT) is not as effective as face-to-face CBT
Many of us feel that online talking therapies are a way of reducing waiting lists, but are bound to be less effective. In fact, they have shown to be equally effective, provided they are therapist-supported. Over the past 20 years, iCBT has been tested in a large number of randomized controlled trials. Most research has demonstrated these interventions are as effective as their F2F equivalents, as well as having comparable completion and dropout rates. Perhaps surprisingly, both treatment formats are also equally effective in treating social anxiety, adolescent anxiety, panic disorder, phobias, with promising results too in post-traumatic stress disorder and obsessive-compulsive disorder. All iCBT programmes offered under the NHS will be NICE-approved, and all will be therapist-supported, which has shown to improve outcomes.
FACTS
Fact 1. Asking someone if they are suicidal can be protective
There is still a concern among lay people and some professionals that talking about suicide to someone with depression can trigger thoughts of self-harm. The opposite is true, however. The Samaritans charity advises that ‘by asking someone directly about suicide, you give them permission to tell you how they feel, and let them know that they are not a burden’. People who have felt suicidal will often say what a huge relief it was to be able to talk about what they were experiencing.
Recognising this, the NICE guidelines on depression in adults advise: ‘Always ask people with depression directly about suicidal ideation and intent.’ For anyone uncomfortable with this, training is available from several sources including the zero suicide alliance.
Fact 2. Depression can present in many ways, particularly as anxiety
Although persistent low mood and loss of interest (anhedonia) are the classic symptoms of depression, it can present in many other ways. More than half the time it is experienced as anxiety. Persistent irritability or anger can be a presenting symptom, as can chronic pain. (In a complex two-way causation, chronic pain can also itself cause depression.) Indeed, in older people somatic symptoms, often without reported mood changes, may be the only presenting features: dizziness, weakness, heavy limbs, lump in throat, constipation, hypochondriasis or agitation are all typical. Symptoms we would think of as pointing to other severe psychiatric illnesses, such as delusions of guilt, poverty or physical illness, or hallucinations with derogatory or obscene content, are typical features of psychotic depression.
Fact 3. Exercise is an effective intervention
A growing body of research shows that exercise is beneficial in reducing depressive symptoms. A recent systematic review concluded that exercise has therapeutic effects on depression in all age groups (mostly 18–65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression.
Fact 4. Antidepressants can increase the risk of suicide
Rates of suicide and self harm are greatly increased in people with depression. Paradoxically, although antidepressants have been shown to be effective in reducing the symptoms of depression, rates of suicide and self harm are increased by treatment in some age groups. A meta-analysis found that among adults aged less than 25 years the risk of suicidal behaviour was increased during treatment with antidepressants, whereas no association was found in adults aged 25 to 64, and in those aged 65 or over the risk was reduced. This increased risk in under 25s is reflected in the updated NICE depression guidelines, which gives specific advice to review this group after a week when starting antidepressants. Although the reason for this increased risk is not fully understood, it is thought that it may arise from the drugs lifting apathy before the antidepressant action kicks in.
Fact 5. Antidepressants are not addictive
This is a somewhat confusing issue, and difficult to explain to patients. In recent years it has become more widely recognised that antidepressants are associated with withdrawal effects, again reflected in the recent guidance which advises us to give patients written guidance on the risk of withdrawal when we initiate a prescription, and to always taper antidepressants gradually on stopping. The likelihood of withdrawal effects is disputed, with different studies showing rates of under 10% to over 50%.
The NHS website defines addiction as ‘not having control over doing, taking or using something to the point where it could be harmful to you’. Withdrawal effects are certainly one aspect of addiction, but others, such as increasing the dosage, spending time thinking about the addiction to the neglect of other areas, hiding or denying the issue, are not present with antidepressants so they are not classed as being addictive.
Dr Peter Bagshaw is a GP and mental health lead at Somerset ICB
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