We keep hearing that GPs are prescribing more and more antidepressants. Latest official NHS prescribing data revealed that, once again, the largest increase in prescribing over the past year has been for antidepressants.
Indeed, antidepressant use in England doubled between 2003 and 2013, and now more than 11% of women and 7% of men are taking them.[1,2] GPs are giving out more than 60 million prescriptions a year, costing around £300 million, and have been accused of over-prescribing for depression.
But the situation is more complicated than that. NICE guidance and the drive to assess severity of symptoms through the QOF was followed by better targeted prescribing, and rates of treating first episodes of depression with antidepressants fell from 72% in 2003 to 61% in 2013.[4,5] This may also have been helped by the expansion of psychological services, although waiting lists are still very long in many areas.
However, antidepressant prescribing is continuing to rise – not because GPs are diagnosing many more people with depression, or starting more of them on treatment, but because they are giving longer courses. Prescriptions per patient doubled over the 10 years between 2003 and 2013, and the median length of treatment is now more than two years.[5–7]
Some of this may reflect a correction of what was previously an inadequate duration of treatment, and it may be that long-term antidepressants are appropriate for some patients to reduce the risk of relapse – NICE recommends treating people for two years in the first instance if there is a history of recurrent depression, or the risk of relapse is significant.[8–10]
However, studies of long-term antidepressant users have concluded that a third to a half have no evidence-based indications to continue them, have a low risk of relapse, and could try stopping treatment.
Unfortunately, the longer patients are on antidepressants the less frequently their treatment is reviewed.[12,13] It’s often easiest just to continue prescribing, assuming that, if the patient is happy to continue them, the risk of relapse is being reduced and no harm is being done.
The dubious rationale for taking SSRIs, promoted by pharma companies, is a deficiency of serotonin in the brain, so some patients believe they have to remain on treatment for life. Many continue indefinitely because they fear relapse and believe discontinuation would be a threat to their stability.
However, antidepressants often cause significant side-effects including weight gain, sleep disturbance, sexual dysfunction, and gastrointestinal bleeding, which increase with longer-term use. In older people they are associated with hyponatraemia, strokes, falls, seizures, and fractures. Long-term treatment can also impair patients’ sense of being able to cope without drugs, increasing their dependence on medical help. For these reasons, no one should be treated with these drugs unnecessarily.
In my view, practices should be auditing their prescriptions of antidepressants regularly, to identify patients taking them for longer than two years and invite them in to discuss discontinuation. Those who may benefit from coming off their antidepressants include patients with a single episode of depression, those with no history of significant impairment and those with a lower risk of relapse (see box).
Patients may need persuading to try withdrawing. They may have tried to stop by themselves and suffered withdrawal symptoms, but most patients can withdraw successfully with slow tapering under supervision. Community pharmacists can help with the tapering, and psychological therapies can help patients who are reluctant to stop because of anxiety about relapse.[7,17–20]
Some GPs may feel nervous about starting to do this in a systematic way and feel they need more support. My group is conducting a six-year programme called REDUCE – funded by the National Institute for Health Research – to develop and evaluate a package of round-the-clock support for practitioners and patients to tackle inappropriate long-term antidepressant prescribing, including more guidance on tapering regimes, internet- and telephone-based support and ‘buddying’ with patients who have successfully withdrawn from long-term treatment.
In the meantime, I believe there is already enough evidence to start a process of audit and review, to reduce the burden of inappropriate antidepressant use in primary care.
Professor Tony Kendrick is professor of primary care at the University of Southampton.
The views expressed are the author’s and not necessarily those of the NHS, the National Insitute for Health Research, or the Department of Health
Who should GPs consider taking off antidepressants?
NICE guidelines only recommend long-term (minimum two years) antidepressant treatment in patients who have had two or more recent episodes of depression with functional impairment, and those particularly at risk of relapse due to life circumstances or previous severe depression.
GPs can therefore consider discontinuing antidepressant therapy in patients who:
- Have had only one episode of depression
- Have had two episodes, but not in recent years
- Have had two or more episodes, but without significant functional impairment
- Have no particular risk factors for relapse (life events and difficulties)
- Have not had severe consequences from depression previously
- Have been taking antidepressants long-term for anxiety disorders.
1. NHS Digital. Prescriptions dispensed in the community: England, 2003 to 2013
3. Spence D. Are antidepressants overprescribed? Yes. BMJ 2013; 346: f191
4. Kendrick T, Dowrick C, McBride A et al. Management of depression in UK general practice in relation to scores on depression severity questionnaires: analysis of medical record data. BMJ 2009; 338: b750
5. Kendrick, T, Stuart, B, Newell, C et al. Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003-2013. J Affect Disord 2015; 186: 171–177
6. Petty D, House A, Knapp P et al. Prevalence, duration and indications for prescribing of antidepressants in primary care. Age Ageing 2006; 35: 523–526
7. Johnson C, Macdonal H, Atkinson P et al. Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study. Br J Gen Pract 2012; 62: 773–779
8. Reid I, Cameron I, MacGillivray S. Increased prescription of antidepressants shows correction of inadequate duration of treatment of depression. BMJ 2014; 348: g228
9. Geddes J, Carney S, Davies C, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 2003; 361(9358): 653–661
10. NICE Clinical Guideline: CG90 – Depression in adults: Recognition and management. 2009
11. Cruickshank G, MacGillivray S, Bruce D et al. Cross-sectional survey of patients in receipt of long-term repeat prescriptions for antidepressant drugs in primary care. Ment Health Fam Med 2008; 5: 105–109
12. Middleton D, Cameron I, Reid I. Continuity and monitoring of antidepressant therapy in a primary care setting. Qual Prim Care 2011; 19(2): 109–113
13. Sinclair J, Aucott L, Lawton K et al. The monitoring of longer term prescriptions of antidepressants: Observational study in a primary care setting. Fam Pract 2014; 31(4): 419–426
14. Dickinson R, Knapp P, House A et al. Long-term prescribing of antidepressants in the older population: a qualitative study. Br J Gen Pr 2010; 60(573): e144–55
15. Ferguson J. SSRI antidepressant medications: adverse effects and tolerability. Prim Care Companion J Clin Psychiatry 2001; 3(1): 22–27
16. Couplan C, Dhiman P, Morriss R et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011; 343: d4551
17. Cromarty P, Jonsson J, Moorhead S, Freeston M. Cognitive behaviour therapy for withdrawal from antidepressant medication: A single case series. Behav Cogn Psychother 2011; 39: 77–97
18. Kuyken W, Hayes R, Barrett B et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet 2015; 386 (9988): 63–73
19. Schmidt N, Wollaway-Bickel K, Trakowski J et al. Antidepressant discontinuation in the context of cognitive behavioral treatment for panic disorder. Behav Res Ther 2002; 40(1): 67–73
20. NHS Digital. Annual Report on the use of IAPT services – England, 2013/14