Depression can have a devastating impact on every aspect of a sufferer’s life, and is all too familiar to millions of people in the UK. Depression makes the single largest contribution to global disability, according to the World Health Organization, and seems to be becoming more common, reflected in the doubling in the number of antidepressants dispensed in England between 2007 and 2017. But does antidepressants’ increasing popularity reflect an epidemic of misuse? Does it reflect limited access to alternative treatments? Or does it reflect that care of this devastating disease is, at last, improving?
Depression is, undoubtedly, common. The latest Adult Psychiatric Morbidity Survey (APMS) 2014, of 16-64 year olds in England, found that one in five women and one in eight men have a common mental disorder, with one in 10 women and one in 16 men experiencing severe symptoms. The three most common disorders were generalised anxiety disorder (GAD; 5.9 per cent), depression (3.3 per cent) and phobias (2.4 per cent). The survey found that mental health disorders are becoming more widespread, rising from 6.9 per cent of 16- to 64-year-olds in 1993, to 9.3 per cent in 2014.
Depression isn’t just a response to the trials and tribulations of adult life. A 2017 report from the Care Quality Commission (CQC) noted that about one in 10 children between the ages of five and 15 are being diagnosed with mental health problems. This estimate is based on a study from 2004, and the CQC suggests that “this is likely to underestimate” the figure. Indeed, other estimates suggest that eight to 20 per cent of adolescents may have depression.
As more people are diagnosed with depression, it’s not surprising that antidepressant prescriptions are rising. According to NHS Digital, in 2017 the NHS dispensed 67.5 million antidepressant items, with a net ingredient cost of just over £235 million: almost double the number dispensed in 2007.
This growing antidepressant prescription rate is partly explained by how several drugs are also approved for increasingly common conditions. Fluoxetine, for example, is also approved for OCD and bulimia; duloxetine for stress incontinence and diabetic peripheral neuropathic pain, and amitriptyline for neuropathic pain, chronic tension headaches and migraines.
In July, The Times reported that 7.3 million people received at least one antidepressant prescription in England during 2017 – equivalent to one in six adults. Patients over 60 were twice as likely to take antidepressants as people in their 20s, while more than 70,000 under 18s (including almost 2,000 primary school children), received antidepressants. But there’s little evidence that most antidepressants are effective in children, and the potential effects on brain development aren’t fully understood.
The Times investigation also revealed marked regional variations. For example, one in five people in Blackpool received antidepressants, compared with less than one in 10 in London, and children in south and north east Lincolnshire were six times more likely than the national average to have been prescribed them.
“It’s important that these figures aren’t automatically seen as a bad thing,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs. “They may indicate that more patients now feel able to disclose mental health problems, and seek medical care and that negative stigma too often associated with mental health conditions is reducing in society.”
Professor Stokes-Lampard noted that The Times’ findings highlight the link between poor mental health and both living in a deprived area and being elderly. “There could be very simple explanations, such as a greater lack of alternative therapies in deprived areas, and increasing levels of social isolation and loneliness in older people,” she said. “More research is needed to properly understand the reasons for both trends, but both clearly need to be addressed.”
Rachel Boyd, information manager at mental health charity Mind, adds: “We know that the number of prescriptions given out for antidepressants has been increasing for several years now. What we don’t know is whether this increase shows a rise in the number of people seeking help, or a rise in the practice of antidepressant prescribing – or both.”
Over the years, studies assessing antidepressants’ effectiveness have reported mixed results, with some suggesting little difference to a placebo. But recent research in The Lancet suggests that antidepressants produce a “modest” improvement in symptoms. Researchers examined 522 studies of 87,052 adults aged over 18 who received antidepressants, and 29,425 taking placebo. Based on the proportion of patients who showed at least a 50 per cent score in reduction of symptoms, all 21 antidepressants studied were more effective than placebo.
The analysis examined only average effects, and not factors that may influence individual responses – such as age, sex, severity or duration of illness – and focused on outcomes at eight weeks, whereas many people need long-term treatment. Indeed, NICE says that people who benefit from an antidepressant should continue taking the medication for at least six months after remission, as continuing treatment “greatly reduces the risk of relapse”. About half of users in the UK have taken antidepressants for longer than two years, and just over a third have taken antidepressants for at least five years.
Coming off antidepressants can prove difficult. NICE states that “antidepressants are not associated with addiction”, which may technically be true, but patients can nevertheless experience withdrawal symptoms including anxiety, flu-like symptoms, insomnia, nausea, dizziness, headache and even hallucinations. Typically, withdrawal reactions last one to two weeks, but may persist for longer.
Based on 14 studies, over half of patients taking antidepressants experienced withdrawal symptoms, with 46 per cent reporting severe symptoms. A survey of 319 people carried out for the All-Party Parliamentary Group for Prescribed Drug Dependence (APPG-PDD) published in September 2018 found that almost half experienced withdrawal symptoms for more than one year, with an average score of nine on a scale of zero to 10 (10 being the most severe withdrawal). Healthcare professionals (HCPs) may misdiagnose withdrawal reactions as a relapse or a poor response, which leads to additional antidepressant prescriptions.
NICE says that patients should be involved in decisions about which medicines they take, but the APPG-PDD also found that 64 per cent of patients said that their doctors did not provide any information on the potential risks and side effects of antidepressants, and 25 per cent were given no advice about how to stop. The study is based on an online survey of those who identified themselves as experiencing withdrawal from psychoactive drugs, particularly antidepressants and benzodiazepines.
“Antidepressants can be effective for some people, but they aren’t the answer for everyone, especially those with mild depression,” says Rachel. “They also come with potential adverse side effects, and we still need to better understand more about how long people are being prescribed antidepressants for and the impact of any long-term prescribing. It’s really important that everyone given a prescription is aware of potential side effects.”
Some people receive antidepressants not because they want to, but because they have little choice. According to NICE, people with persistent sub-threshold symptoms, or mild to moderate depression, should receive individual guided self-help based on cognitive behavioural therapy (CBT), or a structured group physical activity programme.
NICE says, however, that antidepressants might be appropriate if patients have previously experienced moderate or severe depression. Antidepressants may also be appropriate for people who experienced sub-threshold depression for a long time (typically at least two years) or whose symptoms or mild depression persist after other treatments. People with moderate or severe depression should receive antidepressants and high-intensity CBT or interpersonal therapy (ITP).
Patients with anxiety or depression can access talking therapies on the NHS through the Improving Access to Psychological Therapies (IAPT) programmes. In 2016-17, HCPs referred almost 1.4 million people to IAPT. Just over 965,000 started treatment, but three in five did not complete it. Only 49.3 per cent of those who completed treatment moved to recovery; around three in 10 of all referrals. For those people, IAPT is invaluable. Many of those whose symptoms persist or who cannot or will not complete treatment need antidepressants.
In addition, almost nine out of 10 patients waited less than six weeks to start treatment, and nearly all were able to start treatment within 18 weeks. But six weeks is a long time to wait for someone who has debilitating depression. So, patients may need antidepressants in the meantime.
Services are less than optimal in other ways. The CQC noted that mental health services for children and young people are “complex and fragmented”. The report notes that “too many children and young people have a poor experience of care”, and some “are simply unable to access timely and appropriate support”.
“IAPT has helped more people get talking therapies, like CBT and counselling,” Rachel says. “But in some parts of the country, people are facing long waits. It’s possible that those waiting for therapy could be prescribed antidepressants instead or in the interim. Giving people a choice of treatments is important. In addition to medication, people should be able to access alternatives, such as talking therapy, exercise, arts therapy or a combination of some or all of these.”
Tackling depression can be extremely difficult – especially as antidepressants are, at best, only part of the answer. Despite a commitment from the Government to improve mental health services, many people with depression cannot get the timely non-pharmacological help they need on the NHS, and so antidepressants might be the best option. As Rachel concludes: “It’s essential that mental health services don’t take a one-size-fits-all approach, but help people access whatever treatments, or combination of treatments, is best for them.”
One in five women and one in eight men have a common mental disorder