NHS antidepressant prescribing: what do we get for £266m a year?
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1019 (Published 06 March 2018) Cite this as: BMJ 2018;360:k1019
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I will not be alone in feeling unable to answer the question that Summerfield poses (1). I agree with Professor Lawrie that "the remaining questions about the use [of antidepressants] should be addressed in clinical trials” (2). It is more than half a century since antidepressants were first prescribed, yet we rely (in terms of evidence base), on studies confined to short term efficacy (average 8 weeks). Given that most of those who continue on antidepressants do so in the long-term or indefinitely, I consider that it is appalling that such an important aspect, vital to informed consent, continues to be a “remaining question”.
In our approach to “remaining questions” such as this, it is vital that we listen to the experience of those taking antidepressants, and that we do so in a way where we do not judge that experience: whether it may be good, bad or ugly (3).
Arriving at work this morning I was invited to “Putting Caring Conversations into Practice” (4) a resource funded by the Scottish Government and developed by Scottish charity Waverley Care. This resource aims “to break down barriers than can exist between patients and healthcare professionals, encouraging open and honest conversations which achieve positive outcomes for both parties.”
In the weeks that have followed since the release of the Lancet meta-analysis by Cipriani et al, (5) professional use of language has often “deployed” military and criminal metaphors, such as: “war on antidepressants”, “war on depression”, “pill shamers”, “villains” and “demonisers”. Such language, in my opinion, should have no place in our shared aspiration for wellbeing and is likely to “marshal” on-going antisyzygy.
Let us hope that in terms of antidepressant prescribing, and the on-going need to learn about experience beyond the short-term, that we can all be part of caring conversations .
(1) Summerfield, D. NHS antidepressant prescribing: what do we get for £266m a year? Published 06 March 2018. BMJ 2018;360:k1019
(2) Lawrie, S. Rapid Response, published 23 March 2018. http://www.bmj.com/content/360/bmj.k1019/rr-5
(3) Recovery and Renewal: PE01651: Prescribed drug dependence and withdrawal. http://www.parliament.scot/GettingInvolved/Petitions/PE01651
(4) Waverley Care: Putting Caring Conversations into Practice: http://www.caringconversations.scot/
(5) Cipriani A, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet2018;S0140-6736(17)32802-7. doi:10.1016/S0140-6736(17)32802-7. pmid:29477251
Competing interests: In the past I raised a petition with the Scottish Parliament in relation to a Sunshine Act for Scotland: http://www.parliament.scot/GettingInvolved/Petitions/sunshineact
I thank Professor Lawrie for his comments on my Personal View. He questions my statement that no defining biological abnormality has been found in the brains of those diagnosed with 'depression', yet concedes that the serotonin binding studies he refers to are "not scientific facts". This is surely in part because most cases of depression do not show serotonin changes (which cannot therefore be 'defining'), and because no clarity exists regarding their scientific status: are such changes implicated in causation, are they epiphenomenal, are they merely incidental? 'Depression' has to date resisted a huge research effort to pin it down biologically. Indeed the more indiscriminate the application of the category of depression, the more it captures mere situational distress, the more the category is a large mixed bowl of fruit defined only by the prescribing trends and sociocultural shifts I was describing.
Regarding my statement that anti-depressants are non-specific sedatives, I was describing their general characteristics as a class- albeit the SSRI class is less sedative than the tricyclics it replaced. It is no accident that amitryptiline, the first ever anti-depressant, and by far the most sedative, gets better ratings than the rest (as does mirtazepine, the most sedative of the newer compounds). "Anti-depression" is non-specific sedation/emotional distancing. Yes, there are some less sedative/more alerting compounds, notably fluoxetine- this accounts for its significant side-effect profile: anxiety, sleep disturbance, erectile issues.
Competing interests: No competing interests
Summerfield makes many good points but two factual errors and some questionable remarks about the context of antidepressant prescribing (Personal view, 10 March).
Firstly, he makes the oft-repeated but inaccurate statement that there is ‘no consistent defining biological abnormality…in the brains of people with a diagnosis of depression’. There are in fact two systematic reviews of molecular imaging studies in several hundred patients that find reduced serotonin transporter binding in several brain regions, including in unmedicated samples and correlating with severity in eg the amygdala,(1) and in keeping with post mortem studies (2). It would be going too far to represent these as scientific facts but there is definitely more than no evidence. Secondly, it is highly unlikely that ‘antidepressants have non-specific sedative effects’ and nothing else; for example, many of the newer drugs are alerting.
The recent review which appears to have stimulated this and many other critiques in the BMJ and elsewhere found an overall effect size of about 0.3 (3). That is about the same as the average effect of most interventions in medicine, including inhaled steroids for asthma, interferon for multiple sclerosis, and many chemotherapies for cancer; and much higher than thrombolysis for acute stroke or aspirin for the prevention of cardiovascular events (4).
Summerfield is of course right that psychiatry, like the rest of medicine, operates in a socio-cultural context, and that there are risks and adverse effects of the ‘medicalisation of everyday life’ but we doctors do what we can for the patient in front of us – whether that is a child with asthma living in a damp house, treatments for physical disease that reflect the effects of lifestyle related dietary and substance consumption, or depression.
As Summerfield appreciates, there is no “epidemic” of depression,(5) but there is an increasing awareness of and willingness to discuss mental ill-health. It is a moot point as to whether this is a good or a bad thing, but ongoing needless controversy about the effects of antidepressants does us and our patients a disservice. The remaining questions about their use should be addressed in clinical trials.
1. Kambeitz JP, Howes OD. The serotonin transporter in depression: Meta-analysis of in vivo and post mortem findings and implications for understanding and treating depression. J Affect Disord. 2015 Nov 1;186:358-66.
2. Gryglewski G, Lanzenberger R, Kranz GS, Cumming P. Meta-analysis of molecular imaging of serotonin transporters in major depression. J Cereb Blood Flow Metab. 2014 Jul;34(7):1096-103.
3. Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JPT, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JPA, Geddes JR. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018 Feb 20. pii: S0140-6736(17)32802-7.
4. Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106.
5. Baxter AJ, Scott KM, Ferrari AJ, Norman RE, Vos T, Whiteford HA. Challenging the myth of an "epidemic" of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010. Depress Anxiety. 2014 Jun;31(6):506-16
Competing interests: In the past three years, I have received personal fees from Otsuka and Sunovion, and personal and research fees from Janssen.
Is Derek Summerfield making himself available for work in societies which have rolled back or resisted the current 'neoliberal political and economic order': Venezuela or Cuba, perhaps?
Alternatively, he may be looking forward to a post-Brexit Britain, policed by the Daily Mail, in which the stiff upper lips (see Eugene G Breen's response) of 'previous generations' are properly respected. And having more capital than young people they might welcome any reduction in public spending, however small £266 million might seem in overall taxation.
More seriously, he has recently acknowledged to me that it is inconsistent, or even illogical, to dismiss the syndromal nature of depression and then cite research which accepts that syndromal nature (Kirsch et al, 2008) in support. This risks obscuring the very substantial, and possibly complete, placebo response to so-called 'antidepressants'. We should not call mild and moderate depression a 'disease', but in my view to call it a 'disorder' is a reasonable compromise for now. I would go further and shift the focus onto the claims for psychotherapy which are no better evidence-based than for drugs, and potentially as undermining of self-efficacy. The standard intervention for depressive disorder should be interpersonally supportive, and starting off with £266 million does not seem excessive.
Competing interests: No competing interests
I found Dr Summerfield’s article quite interesting. However, I think there are a few points that need clarifying.
Dr Summerfield asserts that there is no conceptual agreement about when a person “really” has a mental disorder. There is indeed an inherent difficulty in defining concepts such as disorder or even health, if we aim to define them on basis of essential criteria, or even using necessary and sufficient conditions. As Keil and colleagues have elaborated in their book, Vagueness in Psychiatry, there is an innate vagueness in concepts of illness and health which is a semantic property of them as linguistic expressions [1]. This is not an epistemic shortcoming which can be eliminated by increasing our knowledge and borderline cases will continue to exist. Moreover, historically we have not defined the concept of disorder as an abstraction and then applied it to target conditions. Given the complexities of human and the brain, applying a lesion theory to mental disorders could be argued to be reductionist.
I share Dr Summerfield’s concerns on the number of prescriptions, however, it is hard to determine what is the acceptable number of prescriptions. And how it is determined? By whom?
The question of what do we get for £266 a year is a legitimate one. I think our patients have to be part of the dialogue to answer that question. I am not sure how we can argue if the society is healthier as the result of the antidepressants as there are several views on what constitutes a healthy society. I share Dr Summerfield’s view that we need to be more resilient and foster resilience. Nevertheless, the same argument can be made around how resilience makes the society healthier. In the end, it is a question of values, and we need to have an honest discussion about them. We must consider our patients’ values and help them in a truly holistic way. Something that could, or could not, include treatment with medications.
1- Keil G,Keuk L, Hauswald R. 2017. Vagueness in Psychiatry. Oxford University Press
Declaration of interest: Dr Summerfield was formerly my supervising consultant and is a dear friend. He has always encouraged independent thinking.
Competing interests: No competing interests
I am not a Psychiatrist, but it seems to me that Dr Green’s final question to Dr Summerfield («What is his suggestion for this epidemic of depression ?») has been already answered, at least in part, in Dr Summerfield’s article, from which I quote verbatim :
Epidemic of depression
« If to have a mental disorder is to have some measure of incapacity, how could one in four UK citizens be thus afflicted and society still keep going as it does?»
Dr Summerfield’s suggestion
« My patients’ presentations often bear out the reality that life in the UK is getting harder: the fortunes of the haves and have-nots are diverging, the fabric of the welfare state thins, employment entitlements grow precarious … the doctor can do little about the patient’s social predicament».
I am not sure whether Dr Summerfield is right, but I would certainly not feel that he is beating about the bush. Indeed, living and working in a particularly deprived area I can often see his point very clearly.
Competing interests: No competing interests
Depression - or what ever you want to call it - is a deadly disease claiming thousands of young lives every year. The morbidity and mortality associated with "it" is enormous. What is it? It is a constellations of symptoms and signs of varying degree and manifestation occurring in otherwise fairly healthy people. There is no blood test or x-ray and no signature except what the patient says and does. It is a diagnosis of history and observation. Its prevalence is of the order of 7-10% of the population.
If you didn't have anti-depressants (as in the 1950s and before) what would happen? Would everyone be more resilient and stiff-upper-lip as Dr Summerfield suggests, and just "get over it?" If you stopped them would the incidence of clinical depression rocket? It is impossible to answer. We are where we are, and whether medication dependence and pharma opportunism has made us into softies relying on pills to cope with the slings and arrows of life, is a possibility as he suggests. However, the horse has bolted and viable alternatives need to be available before taking away a very useful treatment (anti-depressants). Lithium and Clozapine definitely reduce suicidality and psychotic symptoms and mood swings (for their respective illnesses). Medications do work in mental illness and to say that anti-depressants are placebo may be wrong. Talking therapy is effective in mild/moderate depression provided you have medical cover if things don't go right.
To say that 10% of a countries population are on psychiatric medication is a stark acknowledgement that there is a need in this area. Why it is happening and what the root causes are is a topic for another time, but what we do have to cope with it right now are anti-depressants and talk therapy, and before throwing out the baby with the bath water, Dr Summerfield needs to give us another baby (treatment). What is his suggestion for this epidemic of depression?
Competing interests: No competing interests
What indeed do we get? In my own case, many years ago, after the break-up of my first marriage, nothing. Only the Samaritans saved me from suicide. What I needed and was not offered was talking therapy. I had no close relatives in the UK: my parents were dead. But after several years my brother came over for a holiday from Australia, and I talked to him non-stop for a whole week. This did the trick, and I came off all my medication cold turkey. But three months later I discovered a lump in my breast, which turned out to be cancer. Since I was no longer depressed I was able to cope, in spite of the lack in those days of Macmillan nurses, breast-care nurses and so on. I received expert help including counselling from the Bristol Cancer Help Centre, now Penny Brohn Cancer Care. Though I did not have a good prognosis I have survived thirty-one years since then.
It seems that the possible connection between depression and subsequent cancer is now being properly researched, with the aid of the UK Biobank, though it has long been suspected. (1) 'Depression and despair make their registrations not just in the mind but in the body . . . Contemporary medical researchers have been able to make correlations between emotional disturbances and malignancies.'(2) Think of how much money and misery would be saved if our cancer incidence could be reduced. One way might be to improve our mental health services.
I should like to suggest that counselling or psychotherapy, which can often be accessed through voluntary groups in the community, must be offered as an alternative to antidepressants. It needs to be said that Cognitive Behavioural Therapy is not necessarily the answer: CBT focuses on the present, whereas in my experience depression has its roots in the past. The fact that the recent paper on antidepressants in the Lancet (3) made no mention of psychotherapy except to write it off as unavailable 'because of inadequate resources' is to my mind shocking. Surely it should be possible to research its efficacy versus that of antidepressants rather than or in addition to using a placebo? I doubt very much if the cost of eight sessions per patient would exceed £266m a year.
I have to declare an interest: after my recovery from cancer, thirty years ago, I trained as a counsellor and worked in the community for thirteen years in the south of England before coming to Scotland in 2003 to join family members. Here again I find that the waiting list for talking therapy is as much as six months: this has to change.
Heather Goodare
(retired counsellor)
1. Patrice Guex. An Introduction to Psycho-Oncology, translated by Heather Goodare, with an introduction by Karol Sikora (Routledge, London 1994)
2. Lawrence LeShan. You can fight for your life: Emotional Factors in the Treatment of Cancer: Foreword by Carl Simonton, p. xii.
3. Andrea Cipriani, Toshi A Furukawa, Georgia Salanti, Anna Chairmani, Lauren Z. Atkinson, Stefan Leucht et al. Comparative efficacy and acceptability of 23 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet published online 21 February 2018.
Competing interests: No competing interests
Psychiatry: Science or Scientism? The inevitability of overdiagnosis
It is the theory that determines what is observed
– Albert Einstein
Derek Summerfield’s recent BMJ article1, portraying the overuse of psychiatric diagnosis and language, reignites a very old debate. Fifty years ago, three writers in particular – Laing, Illich and Szasz2 – together with activist groups such as People Not Psychiatry, warned us of the traps of unwisely medicalising our mental health and welfare and the price we might pay. Summerfield’s brief contemporary analysis largely endorses these much earlier critics.
Fundamental to these deeply-rooted problems is our overuse, or misuse, of the medical model, and then its mindset, language and interventions – its diagnoses and treatments. This excess and misapplication has evolved largely because of the massive previous successes of the scientifically centred medical model. In the last century it has been spectacular at eliminating, preventing or minimising many previously lethal or crippling physical illnesses. Medical interventions have often unfurled almost Olympian powers over the fate of humanity.
But this success has its dangers: from these indisputable achievements we have all too readily segued to grand-scale misassumptions. We have often wished to believe that all problems presenting to healthcarers could be similarly processed and solved: by expediting our procedures of objectification-diagnosis-treatment. This is consistent with our increasingly technology-dependant lives: almost all that we encounter now is similarly manufactured, standardised, packaged and despatched for our use. So why not expect equivalent psychological or psychiatric treatments to fix our myriad forms of personal and social dis-ease?
Then can we not recruit specialists to fix all our distress and ailments? In particular, to fix our illimitable stress-related and mental health problems?
The misassumption here is crucial: it is that our medical model can be effectively and reliably transferred to, and then mass-produced for, problems that are human rather than biomechanical. This crucial distinction – the human v the biomechanical – corresponds very well to what can be objectively observed and measured, and what cannot. And here begin our many problems of medical modelling throughout pastoral and mental healthcare: this is because we cannot directly measure any experience, for example, ‘depression’, with the same reliability or precision as, say, left ventricular output or serum calcium3. Rigorous and insistent attempts to do so draw us away from true science and into the capricious, yet often authoritarian, realm of scientism: those activities that are attired like science, but which underneath are not and cannot be. Summerfield’s lament of this is trenchant and topical, yet is also a long-delayed echo of our 1960s’ and 1970s’ prophetic luminaries.2
*
We can help ourselves greatly here by considering the difference between scientific attitude and scientific activity. For scientific attitude (dispassionate observation, patterning a hypothesis and prediction; further observation to refute/confirm/reformulate the hypothesis etc) is essential to all intelligent life, certainly any successful human engagement. So our work always needs to be guided by a scientific attitude. But this is very different to submitting to protocols for scientific activity, which is characterised by standardised measurements, schemata and language. The failure to heed this distinction has led to many doomed projects in pastoral healthcare: in particular, mental health services becoming so often in thrall to institutional scientism while increasingly depleted of human sense and sensibility.4 Summerfield is thus readily able to point out the inevitable lack of scientific integrity in psychiatry.1
*
So why have we done this? A brief answer is both ideological and expedient – we have thought we either should or could industrialise and proceduralise our way out of our myriad, tricky human and societal problems by medicalising (and medicating) them. After all, that is the way – mostly – our commodified world works for us now.
And how have we done this? Increasingly by making such poorly grounded science – and then its often shallow or flawed data – the dominant, and often only, currency and language in the NHS.
From the 1980s, coincidental with the first stirrings of marketisation, there have been successive medically modelled reforms of mental health services. These have been designed to short circuit and administratively eliminate the essential human ambiguities so carefully considered by earlier writers and practitioners. Summerfield now describes the ballooning number of sub-specialties, diagnoses4 and prescriptions.5 Few (non-management) veteran observers or practitioners would say that – overall – these expensive changes constitute progress in the quality of our care and understanding.
Not everything that can be counted counts; not everything that counts can be counted.
– Albert Einstein
Shortly before this accelerated hegemony of misassumptions we had another wisely prophetic book, Psychiatry in Dissent,6 by Anthony Clare. It was published in 1976 and so was a kind of swan-song for a culture and health service still permeated by intelligent doubt and searching philosophy. But this erstwhile kind of space – for practitioner reflection and relativism – has been driven out by subsequent managerialism that is insistent on administrative uniformity and clarity but is then inimical to human complexity, variation or experience: instead we have, increasingly, been instructed to proceed by medically-modelled pastoral and mental healthcare.
The result so often is what Summerfield describes: the pullulating of new specialisms, diagnoses and treatments applied by increasingly stressed, alienated and unviable services all clamouring for funding. Summerfield is right, too, in suggesting we must counter these with broader mindsets and languages. Often it is more humane, and eventually more effective (and so more economic) to retranslate the speciously biotechnical back into the language of the personal and the social.
Our excessive, and rapidly increasing, anti-depressant prescribing – the anchored centre of Summerfield’s articles – is but the tip of an enormous iceberg.
Notes and references
1. Summerfield, D ‘NHS antidepressant prescribing – what do we get for £266 million per year?’, British Medical Journal Blog, 27.2.18
2. The following three books are seminal, some would say iconic, from that time. None can instruct us how to run a modern mental healthcare service: yet all contain vital caveats for what we now can (and do) get very wrong:
• Laing RD (1960), The Divided Self. An Existential Study in Sanity and Madness. Penguin.
• Illich, I (1975), Limits to Medicine. Medical Nemesis. The Expropriation of Health. London: Marion Boyars.
• Szasz, T (1961), The Myth of Mental Illness. The manufacture of madness. Harper Collins.
3. Zigmond, D (1976). ‘The medical model. Its limitations and alternatives. How humanism may synergise biomechanism’. Hospital Update, August, 424-427
4. Zigmond, D (2015) ‘Sense and Sensibility’. If You Want Good Personal Healthcare – See a Vet, Section 2, Chapter 10. New Gnosis Press.
5. Summerfield, D (2006) ‘Depression: epidemic or pseudo-epidemic?’, Journal of the Royal Society of Medicine, 99: 161-2
6. Clare A (1976) Psychiatry in Dissent. Controversial Issues in Thought and Practice. Tavistock Press.
Competing interests: No competing interests