Intended for healthcare professionals

Rapid response to:

Head To Head

Are antidepressants overprescribed? Yes

BMJ 2013; 346 doi: (Published 22 January 2013) Cite this as: BMJ 2013;346:f191

Rapid Response:

Re: Are antidepressants overprescribed? Yes

This debate has been running for many years as Des Spence suggests. I tend to side with Prof Reid on the question of whether in general practice, we are now prescribing appropriately.

As Prof Reid points out, amitriptyline is much used for neuropathic pain but also for IBS. Many patients present with anxiety or insomnia as their prime complaint, often alongside fear, low mood or depression. For some years and still sometimes now, amitriptyline’s sedative side effect is used for treating insomnia. This is on a background of sensible guidance suggesting avoiding benzodiazepines for insomnia or anxiety or making short-term use of these and non-benzo sleeping tablets. Mirtazapine is also used quite widely for insomnia having a sedative side effect at the 15mg dose.

I hope that very few GPs prescribe antidepressants when the symptoms are of only two weeks duration – as Dr Spence mention of classification issues might imply.

One aspect which neither writer mentions is the challenge for GP and patient of reducing and stopping the tablets after a six to nine month course and improvement. My experience with many patients is that in the context of their lives where, loss, debt, limited low income, drug misuse and a next crisis just round the corner, the suggestion that they might move to stopping such tablets is greeted with fear and resistance. There is never a right time. Of course we can aim to boost resilience and coping and make good use of talking therapies, in particular Beating the Blues – a computer delivered CBT 8 session programme for anxiety and depression, but that isn’t always acceptable or successful.

So, while as Prof Reid states, an increase of prescription course length from one to six months increases the volume of antidepressants prescribed by six-fold, continuing for three years multiplies that by another six-fold. In my practice, we rarely put antidepressants onto the repeat prescription system, preferring to prescribe for say three months when a patient is going well and review then. That may not be the case for all practices.

Other factors can influence GP behaviour too. As stated by MSP Jim Hume in the Scottish Parliament this week in a debate on the new government mental health strategy: “Currently, the Scottish national average full-time equivalent figure for clinical and other applied psychologists is 11.3 per 100,000 people, with the rate increasing to 14.8 in NHS Greater Glasgow and Clyde and 15.5 in NHS Fife, but it is 10.0 in NHS Grampian, 8.9 in NHS Highland and as low as 7.6 in NHS Forth Valley. People in the NHS Forth Valley area therefore have less than half the number of clinical and applied psychologists of their close neighbours in the NHS Fife area.” Clinical psychology is often the referral destination of those with specific anxiety disorders or not if the wait is many months.

It seems high time that us GPs along with our pharmacy colleagues researched what proportion of patients who are indeed on very long term prescriptions, whether for anxiety disorder, depression or insomnia – and how much that contributes to the total volume of prescribing. I understand that the Royal College of Psychiatrists has been collecting patient experience of this and may produce literature which would help patients and GPs with the reducing and stopping challenge.

Competing interests: No competing interests

25 January 2013
Philip A Gaskell
Allan Park Medical Practice
19 Allan Park Stirling FK8 2QD