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Reserve antidepressants for cases of severe depression, Dutch doctors are told

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e4211 (Published 18 June 2012) Cite this as: BMJ 2012;344:e4211
  1. Tony Sheldon
  1. 1Utrecht

Antidepressant drugs such as serotonin reuptake inhibitors (SSRIs) and tricyclic depressants should be prescribed as the first treatment only in cases of severe depression, says new guidance from the Dutch College of General Practitioners.

It recommends that drug treatment should not be “the first step” for patients exhibiting only “depressive symptoms,” a new category distinct from depression—a move that professional associations believe could substantially reduce the Netherlands’ one million users of antidepressants.

The revised “evidence based professional guidance” recommends that antidepressant treatment should be prescribed from the outset only if the patient’s depression “is accompanied by severe suffering or social dysfunctioning or serious psychiatric comorbidity” such as addiction or anxiety.1

The guidance says that GPs see patients with depressive symptoms more often than those with actual depression, and it believes that doctors therefore need separate diagnostic and therapeutic advice.

It advises that patients with depressive symptoms should at first be given information and, if necessary, help to structure their daily life, together with a short course of psychological treatment. This is, it argues, because of increasing evidence that “non-pharmacological treatment of depressive symptoms” is effective.

Such depressive symptoms and low mood are, it states, often a normal and transient reaction to disappointment or loss and not severe enough to meet criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Only if this treatment is ineffective and the patient’s condition persists is psychotherapy or antidepressants recommended.

The guidance states that a diagnosis of depression requires the presence for two weeks of at least five DSM-IV criteria, including one of two core symptoms: a depressed mood and loss of interest or pleasure in all activities for most of the day, every day. And such a diagnosis, it states, requires a broad exploration of symptoms made in a systematic manner over the course of several visits.

A coauthor of the guidance, Mariëlle van Avendonk, emphasised that many antidepressants are prescribed for anxiety disorders, which were separate from depression. She said, “We don’t know how large the group is who may be incorrectly prescribed antidepressants. It will decline, but by how far I have no idea. The aim is that people with depression and depressive symptoms should receive the best possible treatment according to the current knowledge in the scientific literature.”

Rutger Jan van der Gaag, chairman of the Dutch Psychiatric Association, believes that the guidelines would boost GPs’ confidence in making a diagnosis and then not prescribing antidepressants. He hoped for a “substantial decline” in drug prescribing.

Arnoud van Buuren, chairman of the Dutch Association for Independent Psychologists and Psychotherapists, said that some patients have been prescribed antidepressants “too often, too quickly, and for too long without them really doing much good.” Although GPs would have to make a difficult distinction between symptoms, he hoped that the guideline might achieve a 40% drop in consumption.

Figures from the Dutch Foundation for Pharmaceutical Statistics (www.sfk.nl) show that antidepressants were prescribed to 1.1 million people in 2011, up from 940 000 in 2006.

Notes

Cite this as: BMJ 2012;344:e4211

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