Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2730 (Published 05 December 2023) Cite this as: BMJ 2023;383:p2730Linked News
Curb antidepressant prescribing to improve mental health, say campaigners
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Dear Editor
The UK market for oncology drugs has doubled since 2015. It is expected to grow another 15% per year during the coming 5 years to a stunning 8,5 billion gbp in 2028. This is a call for action to reduce prescriptions of oncology drugs.
167000 people in the UK die of cancer every year, and despite the increase in use of oncology drugs there is only a 10% reduction of death over the last 10 years. Reduced mortality and morbidity seem mainly be a result of early detection and improved surgical techniques. All in all, the oncology drugs have very limited effect in reducing cancer morbidity or mortality. They do however have troublesome, sometimes even lethal, side effects that can be detrimental for the user. It is apparent that oncology drugs cause a lot of harm and provide very limited benefit.
Oncology drugs are often prescribed even for mild (or early) cases of cancer. There are convincing case reports of the strong positive effects of counselling or talking therapy, especially if combined with improvement of socioeconomical factors. Oncology drugs should if anything be reserved for severe cases of cancer, although there is evidence that even for severe cases the impact on mortality is limited.
Cancer is caused by multiple factors, and environmental factors play a huge role in the increase of cancer prevalence. Dietary factors, alcohol, pollution, overweight, smoking etc are the main contributors to cancer morbidity. It would clearly be a better use of the money now invested in oncology drugs to instead target the core causal factors in the environment.
I would believe, and hope, that anyone reading the paragraphs above are appalled and see this as completely absurd. Medicine has made immense advances in the detection and treatment of cancer. Any case of newly discovered cancer would be thoroughly evaluated, and the best combination of treatment will be offered – which can include drug treatment, radiotherapy, surgery, change of life style etc. Noone would argue that one treatment modality should be excluded per definition, in favour of one of the other modalities if a combination is deemed advantageous.
It is saddening, that in psychiatry, when we now are entering 2024, there still are those who represent a polarised view of treatment options. Using oncology drugs as an example tells us, that we of course should have a critical view of the fact that the oncology drug market is constantly growing. We continuously need to evaluate if new treatments offer better effectiveness or value. We need to evaluate if there is sufficient investment in prevention and socio-economic improvements. And that is what we do. But we don’t come to a blanket conclusion, that drug treatments need to decrease broadly. How can it be, that there still are those who see certain psychiatric treatments as something bad that need to be stopped? As Hardelid et al write, the debate would benefit by being based on an understanding that we have several tools in the toolbox, whereof antidepressants is one, and we should jointly concentrate our efforts in improving the different options as well as improving our understanding of individual differences, so that we can improve our capabilities to personalise treatment. If that will decrease the prescriptions of antidepressants remains to be seen.
Competing interests: Options in, and consultant for, GH Research.
Dear Editor
We thank Hardelid and colleagues for their response and would like to reply to their two central contentions.
They cite the 2018 Cipriani meta-analysis as evidence for the effectiveness of antidepressants in moderate to severe depression. There are several methodological limitations to this analysis that have been comprehensively presented in a 2019 BMJ Open paper[1] and elsewhere.[2,3] Presenting data dichotomised into response rates (an arbitrary criterion) inflates small differences between groups on a continuous variable[4] and is recommended against by statisticians.[5] When the data is presented as the underlying continuous depression scale the difference is less than 2 points on the 52-point HDRS scale, which is less than even the most lenient threshold for a minimum clinically important difference (MCID).[6]
Even this small difference is likely to be exaggerated by unblinding effects induced by antidepressants (which are larger than 2 points on the HDRS in studies that have isolated these effects).[7] The average duration of studies is only 8 weeks, while many patients take antidepressants for months, years or decades. Withdrawal effects from previously used antidepressants stopped before randomisation in these RCTs exaggerate the beneficial effects of the drugs, as does publication bias.[1] Lastly, antidepressants may improve depression scores by, for example, numbing effects (which are commonly reported by patients on antidepressants and are also induced in health volunteers[8]), without changing the course of the underlying condition.
Our correspondents suggest that some people may benefit more than average but a meta-analysis they have conducted shows that effects at any baseline severity of depression fails to meet a MCID.[9] Attempts to identify different patterns of response to antidepressants are provisional, only examine 8-week data and have not identified any characteristics of individuals that would predict a larger response.[10]
They cite a network meta-analysis (NMA) from Cuijpers to suggest equal efficacy between psychotherapy and pharmacotherapy – but a more recent and larger NMA by the same group shows that while the effects are equivalent in the short-term psychotherapies produce substantially better outcomes (Hedges’ g of 0.32) over more than 6 months follow-up.[11]
Regarding the second point, we agree with our correspondents that there are possible confounders to the association between prescription of antidepressants and worsening mental health outcomes and strong conclusions are not possible. It is a concern that there are no long-term randomised trials, but observational studies are not encouraging, showing either no difference[12] or worsened outcomes (limited by potential residual confounding).[13] Proposed alternative explanations are not proven. When effective treatments are introduced the morbidity of the conditions being treated tends to reduce (e.g. insulin prescription and amputation of gangrenous limbs). Each year 1 million people receive IAPT treatment, while 8 million receive antidepressants, the dominant treatment approach.
Analogy with cardiovascular disease trends is misleading: they cite rising prescription of cardiovascular treatment in the OECD between 2000 and 2015 but cite rising death rates across the entire world. In fact, according to the OECD itself, cardiovascular mortality fell by over 47% in OECD countries between 2000 and 2019.[14] In other words, an increase in these treatments were associated with a fall in the conditions they treat, despite other ongoing factors driving disease.
Given the evidence for antidepressants prescribing is short-term and methodologically flawed, existing evidence on long-term outcomes is consistent with no or negative effects, there are numerous adverse effects and multiple alternative treatments show evidence of equal efficacy in the short term and some show better efficacy in the long-term, reduction in the prescribing of antidepressants, especially for mild conditions, is a prudent step. Long-term RCTs to evaluate the full range of benefits and harms are urgently needed.
References
1 Munkholm K, Paludan-Müller AS, Boesen K. Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis. BMJ Open 2019;9:e024886. doi:10.1136/bmjopen-2018-024886
2 Moncrieff J. What does the latest meta-analysis really tell us about antidepressants? Epidemiol Psychiatr Sci 2018;27:430–2. doi:10.1017/S2045796018000240
3 Horowitz M, Wilcock M. Newer generation antidepressants and withdrawal effects: reconsidering the role of antidepressants and helping patients to stop. Drug Ther Bull 2022;60:7–12. doi:10.1136/dtb.2020.000080
4 Kirsch I, Moncrieff J. Clinical trials and the response rate illusion. Contemp Clin Trials 2007;28:348–51. doi:10.1016/j.cct.2006.10.012
5 Altman DG, Royston P. The cost of dichotomising continuous variables. BMJ 2006;332:1080. doi:10.1136/bmj.332.7549.1080
6 Hengartner MP, Plöderl M. Estimates of the minimal important difference to evaluate the clinical significance of antidepressants in the acute treatment of moderate-to-severe depression. BMJ evidence-based medicine Published Online First: February 2021. doi:10.1136/bmjebm-2020-111600
7 Faria V, Gingnell M, Hoppe JM, et al. Do You Believe It? Verbal Suggestions Influence the Clinical and Neural Effects of Escitalopram in Social Anxiety Disorder: A Randomized Trial. EBioMedicine 2017;24:179–88. doi:10.1016/j.ebiom.2017.09.031
8 Langley C, Armand S, Luo Q, et al. Chronic escitalopram in healthy volunteers has specific effects on reinforcement sensitivity: a double-blind, placebo-controlled semi-randomised study. Neuropsychopharmacology Published Online First: 23 January 2023. doi:10.1038/s41386-022-01523-x
9 Furukawa TA, Maruo K, Noma H, et al. Initial severity of major depression and efficacy of new generation antidepressants: individual participant data meta-analysis. Acta Psychiatr Scand 2018;137:450–8. doi:10.1111/acps.12886
10 Stone MB, Yaseen ZS, Miller BJ, et al. Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis. BMJ 2022;378:e067606. doi:10.1136/bmj-2021-067606
11 Cuijpers P, Miguel C, Harrer M, et al. Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry 2023;22:105–15. doi:10.1002/wps.21069
12 Hughes S, Cohen D. A systematic review of long-term studies of drug treated and non-drug treated depression. J Affect Disord 2009;118:9–18. doi:10.1016/j.jad.2009.01.027
13 Hengartner MP, Angst J, Rössler W. Antidepressant Use Prospectively Relates to a Poorer Long-Term Outcome of Depression: Results from a Prospective Community Cohort Study over 30 Years. Psychother Psychosom 2018;87:181–3. doi:10.1159/000488802
14 Mortality from circulatory diseases. https://www.oecd-ilibrary.org/sites/ae066b01-en/index.html?itemId=/conte... (accessed 20 Dec 2023).
Competing interests: JD is a practising psychotherapist; co-founder of the Council for Evidence Based Psychiatry; and secretariat member of the All-Party Parliamentary Group for Prescribed Drug Dependence. He has royalties on authored and edited books. JR is chair of the International Institute for Psychiatric Drug Withdrawal. JM declares: National Institute of Health Research programme development grant, Radar follow-up study, chief investigator, 2022-24; National Institute of Health Research programme grant REDUCE study of antidepressant discontinuation co-investigator, 2017-23; co-applicant on the RELEASE trial funded by the Medical Research Future Fund in Australia; royalties on authored and edited books; lecture fees received from Alberta Psychiatric Association, British Psychological Association, Université de Sherbrooke, Case Western Reserve University, University of Basel; co-chair person, Critical Psychiatry Network; unpaid board member of non-profit Council for Evidence Based Psychiatry. AG is a member of the Council for Evidence Based Psychiatry and secretariat member of the Beyond Pills All-Party Parliamentary Group. MH is a collaborating investigator on the NHMRC and MRFF funded RELEASE and RELEASE+trials in Australia investigating supported, hyperbolic tapering of antidepressants; is a co-founder of Outro Health, a digital clinic which aims to help people who want to stop taking no longer needed antidepressant medication in North America using supported, hyperbolic tapering; has received honoraria for lectures on deprescribing from NHS trusts, Washington University, and the University of Arizona. PK is a member of the NICE Clinical Guidelines Panel; is director of Kinderman Consulting; has received royalties on published work in the field of mental health; is a clinical adviser to Public Health England; has received research grants from the National Institute of Health Research, the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust, the Youth Justice Board for England, various NHS trusts, the Department of Health and Social Care, the European Commission, the British Psychological Society, and the Reader Organisation; has received personal fees from the Department for Constitutional Affairs, legal counsel, BBC, Al Jazeera, Smoking Gun Media, GLG Group, True North Productions, Warrington Borough Council, and Compass Pathways. RP receives research funding from the NIHR for research into polypharmacy and deprescribing. All other authors have none to declare.
Dear Editor
We thank Jauhar and colleagues for their comments on our letter. Their overall point seems to be that the current scale of antidepressant use is not of concern, and that the use of antidepressants for mild conditions and those provoked by social and economic conditions is justified. We address their points in order.
Antidepressants lead to a range of adverse events as evidenced in matched comparisons of antidepressant users showing a higher incidence of increased weight gain[1] and increases in falls, cardiovascular disease, bleeding and mortality.[2] These studies carry a risk of residual confounding but they are consistent and highlight the lack of long-term randomised trials that can establish the incidence, prevalence and severity of antidepressant adverse effects definitively, which is a concern for all, but particularly those with milder conditions. A precautionary approach would be prudent. More than 50% of patients using common antidepressants experience treatment-emergent sexual dysfunction in double-blind randomised controlled trials,3 which, according to the EMA, can persist after cessation.[4]
They question the extent of withdrawal symptoms. They give a "worst case" scenario figure of symptoms in 25% of people. This still represents millions of people but the evidence they cite is for patients who have been on antidepressants for just 17.2 weeks on average.[5] The median duration of antidepressant use is more than 2 years in the UK [6] and there is a clear dose-response relationship between duration of use and risk of withdrawal effects, with incidence and severity rising after 6 months of use.[7] Double-blind randomised controlled trials (conducted by drug companies) demonstrate that 50% of patients stopping antidepressants experience withdrawal effects.[7] The RCT in the NEJM does not measure the severity of withdrawal per se, but usefully demonstrated withdrawal effects that lasted for months on average,[8] consistent with a protracted withdrawal syndrome.[9]
The recent Lancet Psychiatry analysis cited to show core depression symptoms are improved by antidepressants compared to placebo in mild depression does not examine mild depression as it used a Hamilton Depression Rating Scale (HDRS) cut-off of 18 points, which is above the level of mild depression (16 or less). In any case, like other meta-analyses, it found minimal differences on the total HDRS in people with depression, below any criteria for clinical significance,[10] and there is no consensus that the subsets of symptoms they select are, in fact, ‘core depression symptoms’. Analyses specifically of mild depression have found no evidence of useful effects.[11]
There is no recent, good quality evidence on the extent of use of antidepressants for mild depression but it is estimated the overwhelming majority of depression is mild (though these people will not all receive antidepressants).[12] Further, repeated analyses show that 30-50% of patients on antidepressants have no evidence-based reason for continuing on them (including that they may have improved during their period on medication).[13]
Jauhar and colleagues acknowledge the role of social circumstances in causing depression but we would question their implication that antidepressants are an acceptable substitute for social and economic measures to address social deprivation.
They criticise IAPT but NICE identifies 18 non-pharmacological alternatives to antidepressants for depression, including 10 for mild depression that are as effective and cost-effective,[14] although the NICE cost-benefit analysis largely neglects the cost of adverse effects, long-term outcomes (better for psychotherapy than medication)[15] and the difficulties people have in stopping these treatments.
We suggest a reduction in antidepressant prescribing is realistic, desirable and can be achieved by more discerning prescription, addressing social and psychological aspect of distress with appropriate measures at the individual and social level, regular review of ongoing prescriptions and supported and safe deprescribing where indicated.
References
1 Gafoor R, Booth HP, Gulliford MC. Antidepressant utilisation and incidence of weight gain during 10 years’ follow-up: population based cohort study. BMJ 2018; 361: k1951.
2 Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011; 343: d4551.
3 Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol 2009; 29: 259–66.
4 Reisman Y. Post-SSRI sexual dysfunction. BMJ 2020; 368. DOI:10.1136/bmj.m754.
5 Baldwin DS, Montgomery SA, Nil R, Lader M. Discontinuation symptoms in depression and anxiety disorders. Int J Neuropsychopharmacol 2007; 10: 73–84.
6 Johnson CF, Macdonald HJ, Atkinson P, Buchanan AI, Downes N, Dougall N. Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study. Br J Gen Pract 2012; 62: e773–9.
7 Horowitz MA, Framer A, Hengartner MP, Sørensen A, Taylor D. Estimating risk of antidepressant withdrawal from a review of published data. CNS Drugs 2023; 37: 143–57.
8 Lewis G, Marston L, Duffy L, et al. Maintenance or Discontinuation of Antidepressants in Primary Care. N Engl J Med 2021; 385: 1257–67.
9 Cosci F, Chouinard G. Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications. Psychother Psychosom 2020; 89: 283–306.
10 Hengartner MP, Plöderl M. Estimates of the minimal important difference to evaluate the clinical significance of antidepressants in the acute treatment of moderate-to-severe depression. BMJ evidence-based medicine 2021; published online Feb. DOI:10.1136/bmjebm-2020-111600.
11 Barbui C, Cipriani A, Patel V, Ayuso-Mateos JL, van Ommeren M. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry 2011; 198: 11–6, sup 1.
12 National Institute for Health and Care Excellence. Depression in adults: recognition and management. (NICE Guideline 90). London: NICE., 2009 https://www.nice.org.uk/guidance/cg90.
13 Kendrick T. Strategies to reduce use of antidepressants. Br J Clin Pharmacol 2021; 87: 23–33.
14 National Institute of Social and Care Excellence. Depression in adults: treatment and management | Guidance | NICE. 2022; published online June. https://www.nice.org.uk/guidance/ng222 (accessed July 16, 2022).
15 Cuijpers P, Miguel C, Harrer M, et al. Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry 2023; 22: 105–15.
Competing interests: JD is a practising psychotherapist; co-founder of the Council for Evidence Based Psychiatry; and secretariat member of the All-Party Parliamentary Group for Prescribed Drug Dependence. He has royalties on authored and edited books. JR is chair of the International Institute for Psychiatric Drug Withdrawal. SH is an officer of the All-Party Parliamentary Group for Prescribed Drug Dependence. JM declares: National Institute of Health Research programme development grant, Radar follow-up study, chief investigator, 2022-24; National Institute of Health Research programme grant REDUCE study of antidepressant discontinuation co-investigator, 2017-23; co-applicant on the RELEASE trial funded by the Medical Research Future Fund in Australia; royalties on authored and edited books; lecture fees received from Alberta Psychiatric Association, British Psychological Association, Université de Sherbrooke, Case Western Reserve University, University of Basel; co-chair person, Critical Psychiatry Network; unpaid board member of non-profit Council for Evidence Based Psychiatry. AG is a member of the Council for Evidence Based Psychiatry and secretariat member of the Beyond Pills All-Party Parliamentary Group. MH is a collaborating investigator on the NHMRC and MRFF funded RELEASE and RELEASE+trials in Australia investigating supported, hyperbolic tapering of antidepressants; is a co-founder of Outro Health, a digital clinic which aims to help people who want to stop taking no longer needed antidepressant medication in North America using supported, hyperbolic tapering; has received honoraria for lectures on deprescribing from NHS trusts, Washington University, and the University of Arizona. PK is a member of the NICE Clinical Guidelines Panel; is director of Kinderman Consulting; has received royalties on published work in the field of mental health; is a clinical adviser to Public Health England; has received research grants from the National Institute of Health Research, the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust, the Youth Justice Board for England, various NHS trusts, the Department of Health and Social Care, the European Commission, the British Psychological Society, and the Reader Organisation; has received personal fees from the Department for Constitutional Affairs, legal counsel, BBC, Al Jazeera, Smoking Gun Media, GLG Group, True North Productions, Warrington Borough Council, and Compass Pathways. RP receives research funding from the NIHR for research into polypharmacy and deprescribing. All other authors have none to declare.
Dear Editor,
We read the letter by Davies et al(1) with interest. We are academics, health researchers and clinicians who have studied the efficacy and mechanisms of antidepressants (CH, AC and TAF) over many years, and who have experienced both benefits and side effects of antidepressants first hand (PH). We agree that unwarranted drug treatment should be, and that patients should be given clear, evidence-based and up-to-date information about antidepressant side effects and withdrawal symptoms so that they can make informed decisions about starting treatment. However, we are concerned that Davies’s article a) lacks key information about the effectiveness of antidepressants and b) misrepresents associational evidence regarding antidepressant prescribing and the prevalence of mental health conditions as causal.
Regarding a), there is a large body of literature, including randomised controlled trials, demonstrating the efficacy of antidepressants for moderate to severe depression. In the largest network meta-analysis to date across 116 477 participants, there was robust evidence showing that antidepressant drugs are on average more effective than placebo treatment, with odds ratios ranging from 1.37 to 2.13. (2) Translated into percentages, the average response to placebo in trials is 37%; by contrast, in the same trials, the average response to antidepressants ranges between 45% (reboxetine) and 56% (amitriptyline). A network meta-analysis (3) including head-to-head comparisons between pharmacotherapies and psychotherapies has shown that they are on average equally efficacious (or inefficacious if we follow Davies et al’s thresholds) among people with diagnosed depression.
Some people will probably experience greater benefits from antidepressants, whereas others might have no benefit.(2)
Individual patient data network meta-analyses would be one powerful step towards enabling personalised treatment in psychiatry. Of course, we also need better treatments for depression that, whether pharmacological or non-pharmacological, are more precisely targeted at mechanism and better tolerated .(4)
Regarding b), the authors state ‘Rising antidepressant prescribing is not associated with an improvement in mental health outcomes at the population level, which, according to some measures, have worsened as antidepressant prescribing has risen.’ Rather than a formal time trends study using age and sex adjusted rates, they reference a 2011 discussion paper(5) which, without statistical analyses, associates trends in numbers of prescribed antidepressant with annual numbers of incapacity benefit claimants in England during the 1990s and 2000s.
The prevalence of mental health conditions has indeed increased in the UK (6) and globally(7) since the 1990s, which, combined with reduced stigma surrounding common mental illness, has led to more people seeking treatment. Indeed, the number of referrals to cognitive behavioural therapy via the IAPT programme has also increased since 2012.(8) The rise in antidepressant prescribing in the UK over the last 20 years therefore likely reflects an increase in the population prevalence of common mental health conditions requiring treatment, rather than driving mental ill-health as implied by Davies et al. As a parallel, we note prescriptions of hypertensive and cholesterol-lowering drugs have doubled to quadrupled in OECD countries between 2000 and 2015; yet deaths due to cardiovascular diseases (CVDs) increased by 49% and years-lived-with-disability (YLDs) associated with CVDs increased by 88% between 1990 and 2017 across the world.(9)
The National Institute of Health and Care Excellence recommends multiple options for first line treatment of depression,(10) one of which is SSRI antidepressants. Patients should have timely access to all options, including talking therapies. However, we are concerned that articles such as those by Davies et al, by misrepresenting the potential effectiveness of antidepressants, can be harmful, as they may prevent patients from accessing treatments which may help them.
1. Davies J, Read J, Kruger D, Crisp N, Lamb N, Dixon M et al. Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing BMJ 2023; 383 :p2730 doi:10.1136/bmj.p2730
2. Cipriani A, Salanti G, Furukawa TA, Egger M, et al. Antidepressants might work for people with major depression: where do we go from here? Lancet Psychiatry. 20185(6):461-463. doi: 10.1016/S2215-0366(18)30133-0.
3. Cuijpers P, Noma H, Karyotaki E, Vinkers CH, Cipriani A & Furukawa TA (2020) A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19, 92-107. https://doi.org/10.1002/wps.20701
4. Cipriani A, Seedat S, Milligan L, Salanti G, et al. New living evidence resource of human and non-human studies for early intervention and research prioritisation in anxiety, depression and psychosis. BMJ Ment Health. 2023;26(1):e300759. doi: 10.1136/bmjment-2023-300759.
5. Middleton H, Moncrieff J. ‘They won't do any harm and might do some good’: time to think again on the use of antidepressants? British Journal of General Practice 2011; 61 (582): 47-49. DOI: https://doi.org/10.3399/bjgp11X548983
6. Dykxhoorn J, Osborn D, Walters K, Kirkbride JB, Gnani S, Lazzarino AI. Temporal patterns in the recorded annual incidence of common mental disorders over two decades in the United Kingdom: a primary care cohort study. Psychological Medicine. 2023:1-12. doi:10.1017/S0033291723002349
7. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019 The Lancet Psychiatry, Volume 9, Issue 2, 137 - 150
8. NHS Digital. Psychological Therapies, Annual report on the use of IAPT services, 2021-22 https://digital.nhs.uk/data-and-information/publications/statistical/psy...
9. Furukawa TA, Kessler RC. Why has prevalence of mental disorders not decreased as treatment has increased? Australian & New Zealand Journal of Psychiatry. 2019;53(12):1143-1144. doi:10.1177/0004867419886652
10. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NICE Guideline 2022. https://www.nice.org.uk/guidance/ng222
Competing interests: PH is supported by the NIHR GOSH Biomedical Research Centre. She has taken antidepressant medication for many years. AC is supported by the National Institute for Health Research (NIHR) Oxford Cognitive Health Clinical Research Facility, by an NIHR Research Professorship (grant RP-2017-08-ST2-006), by the NIHR Oxford and Thames Valley Applied Research Collaboration and by the NIHR Oxford Health Biomedical Research Centre (grant NIHR203316). He has received research, educational and consultancy fees from INCiPiT (Italian Network for Paediatric Trials), CARIPLO Foundation, Lundbeck and Angelini Pharma. He is the CI/PI of one trial about seltorexant in adolescent depression, sponsored by Janssen. The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR, or the UK Department of Health. CH is supported by the NIHR Oxford Health Biomedical Research Centre (grant NIHR203316). She has received research, educational or consultancy fees from Johnson and Johnson, Lundbeck, Compass, P1vital, Zogenix, UCB and Cambridge University Press within the last 3 years. She has collaborated with Pfizer on an MRC funded grant. TAF reports personal fees from Boehringer-Ingelheim, DT Axis, Kyoto University Original, Shionogi, SONY and UpToDate, and a grant from Shionogi, outside the submitted work; In addition, TAF has patents 2020-548587 and 2022-082495 pending, and intellectual properties for Kokoro-app licensed to Mitsubishi-Tanabe.
Dear Editor
A prescription error
We respond to the letter by Davies et al [1], calling for a reduction in antidepressant prescribing.
They argue that, as antidepressant prescribing has doubled, and that, due to their side effects, and limited efficacy, use should be curtailed in mild conditions. Sadly the evidence cited, inferences drawn and alternatives proposed make it difficult to see how large-scale health benefits could result.
The authors state adverse event, including "weight gain, sexual dysfunction, falls and poorer long-term outcomes for women." without giving any citation, or measure of magnitude.
They state withdrawal symptoms "are experienced by around half of patients, with up to half of those describing their symptoms as severe, and a substantial proportion experiencing withdrawal for many weeks, months, or longer." The citation is a flawed review [2], and severity is taken from surveys, including people using tapering kits and through websites for people experiencing withdrawal symptoms- inference is therefore impossible. "Worst case" scenarios from RCTs (ie abruptly stopping antidepressants known to cause withdrawal) suggest symptoms in 25% [3], with severity being much lower in most people, observed in a recent NEJM RCT [4].
On efficacy for mild depression, the authors cite a 2008 meta-analysis which showed negligible effects [5], and suggest this is what motivated NICE to suggest antidepressants are not offered first-line. There is an ecological fallacy to this analysis (ie group opposed to individual level analysis), a relatively recent Lancet Psychiatry analysis and Comment indicating individual level data of core depression symptoms showed significant effects with antidepressants compared to placebo in mild depression [6][7].
Evidence on antidepressants in primary care for mild to moderate depression consists of a study in elderly US patients from 2005-2008 [8] and "Another UK study showed that 58% of people taking antidepressants for more than two years failed to meet criteria for any psychiatric diagnosis." This cross-sectional 2008 study in 92 people stated in the discussion that these findings could be attributed to beneficial effects of antidepressants [9]. Rates of antidepressant prescribing for mild cases are not given, and the current number represents around 18% of the population. A 2011 WHO study estimated lifetime prevalence of DSM-IV Major Depresssive Disorder in high income countries as 14.6%, and annual incidence around 5% [10].
The comment that rates of antidepressant prescribing is disproportionately higher in women, older people and those from deprived areas neglects confounding by indication - higher rates of depression in these populations have been acknowledged for decades.
In commenting on costs of antidepressants they do not breakdown on indication for use - for example, SSRI antidepressants now supersede benzodiazepines as first-line pharmacological treatments for anxiety disorders [11].
Alternatives to antidepressants include psychosocial interventions and social prescribing.
The Improving Access to Psychological Therapies (IAPT) scheme has been a major policy initiative for over a decade, involves provision of NICE-approved psychotherapies for anxiety and depression amongst other conditions, and has cost over £1 billion [12]. Increased antidepressant prescribing has occurred despite IAPT. Furthermore there remain no clear conclusions on IAPT's cost-effectiveness [13], and suggestion that it is probably not cost effective [14]. Dropout rates are significant for all treatments, and whilst NICE does not suggest routine prescribing of antidepressants for less severe depression, it does suggest patient choice (including antidepressants).
Therefore it is difficult to see how either the witholding of antidepressants can practically take place, and evidence given to curtail use is underwhelming.
Only societal changes, such as decreasing relative deprivation will have large population effects, and we would suggest the valuable time of politicians and others may be better spent addressing these important issues.
References
1 Davies J, Read J, Kruger D, et al. Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. BMJ. 2023;383:p2730.
2 Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav. Published Online First: 4 September 2018. doi: 10.1016/j.addbeh.2018.08.027
3 Jauhar S, Hayes J, Goodwin GM, et al. Antidepressants, withdrawal, and addiction; where are we now? J Psychopharmacol (Oxford). 2019;269881119845799.
4 Lewis G, Marston L, Duffy L, et al. Maintenance or Discontinuation of Antidepressants in Primary Care. New England Journal of Medicine. 2021;385:1257–67.
5 Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5:e45.
6 Hieronymus F, Lisinski A, Nilsson S, et al. Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis. Lancet Psychiatry. 2019;6:745–52.
7 Furukawa TA. Baseline severity and efficacy of antidepressants: into the third generation of research. Lancet Psychiatry. 2019;6:715–6.
8 Shim RS, Baltrus P, Ye J, et al. Prevalence, Treatment, and Control of Depressive Symptoms in the United States: Results from the National Health and Nutrition Examination Survey (NHANES), 2005–2008. J Am Board Fam Med. 2011;24:33–8.
9 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;5:105–9.
10 Bromet E, Andrade LH, Hwang I, et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med. 2011;9:90.
11 Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28:403–39.
12 Marks DF. IAPT under the microscope. J Health Psychol. 2018;23:1131–5.
13 Thornicroft G. Improving access to psychological therapies in England. The Lancet. 2018;391:636–7.
14 McCrone P. IAPT is probably not cost-effective. Br J Psychiatry. 2013;202:383.
Competing interests: SJ has given non promotional talks on antipsychotics for Sunovian, Lundbeck and Janssen, and on schizophrenia for Boehringer-Ingelheim. SJ has consulted for LB pharmaceuticals on antipsychotics. SJ has sat on a funding panel for the Wellcome Trust and as an expert advisor for NICE on medications for tardive dyskinesia. SJ is an elected member of Council for the British Associaotin for Psychopharmacology (unpaid). DJN Advisor-British National Formulary Chair-Drug Science UK and PAREA Europe Member International Centre for Science in Drug Policy CRO-Awaknlifesc iences Editor of the Journal; Drug Science Policy and Law Member Lundbeck Foundation, Neurotorium programme and Chair of the Editorial Board Grants for clinical trial payments; Wellcome Trust, MRC, COMPASSPathwaysUsona Speaking honoraria Lundbeck, Janssen, Otsuka, Rovi Share options; P1vital,, Awakn, PsychedWellness, Neurotherapeutics Director Equasy Enterprises and GABA Labs Expert witness in a number of legal casesrelating to psychotropic drugs Editor/written 38 books, some purchased by pharmaceutical companies. Prof. Pariante is funded by a Senior Investigator award from the National Institute for Health Research (NIHR); the Medical Research Council (grants MR/L014815/1, MR/J002739/1 and MR/N029488/1); the European Commission (EARLYCAUSE grant SC1-BHC-01-2019); the NARSAD; the Psychiatry Research Trust; and the Wellcome Trust (SHAPER, Scaling-up Health-Arts Programme to scale up arts interventions, grant 219425/Z/19/Z). He has also received research funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 853966-2, as part of the EU-PEARL project; this Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. Less than 10% of his support in the last 10 years derives from commercial collaborations, including consultation and speakers fees from Boehringer Ingelheim, Eli Lilly, Compass, Eleusis, GH Research, Lundbeck, and Värde Partners. AHY is employed by King’s College London; Honorary Consultant South London and Maudsley NHS Foundation Trust (NHS UK) Editor of Journal of Psychopharmacology and Deputy Editor, BJPsych Open, Paid lectures and advisory boards for the following companies with drugs used in affective and related disorders: Flow Neuroscience, Novartis, Roche, Janssen, Takeda, Noema pharma, Compass, Astrazenaca, Boehringer Ingelheim, Eli Lilly, LivaNova, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allegan, Bionomics, Sumitomo Dainippon Pharma, Sage, Neurocentrx Principal Investigator in the Restore-Life VNS registry study funded by LivaNova. Principal Investigator on ESKETINTRD3004: “An Open-label, Long-term, Safety and Efficacy Study of Intranasal Esketamine in Treatment-resistant Depression.” Principal Investigator on “The Effects of Psilocybin on Cognitive Function in Healthy Participants” Principal Investigator on “The Safety and Efficacy of Psilocybin in Participants with Treatment-Resistant Depression (P-TRD)” Principal Investigator on ‘’A Double-Blind, Randomized, Parallel-Group Study with Quetiapine Extended Release as Comparator to Evaluate the Efficacy and Safety of Seltorexant 20 mg as Adjunctive Therapy to Antidepressants in Adult and Elderly Patients with Major Depressive Disorder with Insomnia Symptoms Who Have Responded Inadequately to Antidepressant Therapy.’’ (Janssen) Principal Investigator on ‘’An Open-label, Long-term, Safety and Efficacy Study of Aticaprant as Adjunctive Therapy in Adult and Elderly Participants with Major Depressive Disorder (MDD).’’ (Janssen) Principal Investigator on ‘’A Randomized, Double-blind, Multicentre, Parallel-group, Placebo-controlled Study to Evaluate the Efficacy, Safety, and Tolerability of Aticaprant 10 mg as Adjunctive Therapy in Adult Participants with Major Depressive Disorder (MDD) with Moderate-to-severe Anhedonia and Inadequate Response to Current Antidepressant Therapy.’’ Principal Investigator on ‘’A Study of Disease Characteristics and Real-life Standard of Care Effectiveness in Patients with Major Depressive Disorder (MDD) With Anhedonia and Inadequate Response to Current Antidepressant Therapy Including an SSRI or SNR.’’ (Janssen) UK Chief Investigator for Compass; COMP006 & COMP007 studies UK Chief Investigator for Novartis MDD study MIJ821A12201 Grant funding (past and present): NIMH (USA); CIHR (Canada); NARSAD (USA); Stanley Medical Research Institute (USA); MRC (UK); Wellcome Trust (UK); Royal College of Physicians (Edin); BMA (UK); UBC-VGH Foundation (Canada); WEDC (Canada); CCS Depression Research Fund (Canada); MSFHR (Canada); NIHR (UK). Janssen (UK) EU Horizon 2020 No shareholdings in pharmaceutical companies
Dear Editor,
The British Society of Lifestyle Medicine (BSLM) supports the call to address the rising rates of antidepressant prescribing and the newly formed “Beyond Pills” All Party Parliamentary Group (previously the APPG for Prescribed Drug Dependence) (1). The discipline of Lifestyle Medicine addresses the gap in knowledge and training required by clinicians to deliver the aims of this campaign. The practice of Lifestyle Medicine offers all the options for health, not just medications or surgery. For example, systematic reviews and meta-analyses of randomised controlled trials suggest that interventions to improve physical activity (2) and nutrition (3) may be as effective as antidepressants for some people. Whilst evidence for social interventions is emerging and needs more research (4).
For too long, medical training and healthcare systems have neglected to sufficiently explore or offer support to patients for all evidenced treatment options including lifestyle approaches. The medical landscape is now changing with organisations such as the BSLM (5) who have driven the growth of the evidenced medical discipline of Lifestyle Medicine.
Lifestyle Medicine is a global movement with curricula, training standards, qualifications (Certification, Accreditation and Master’s), conferences and journals. Lifestyle Medicine training is framed around 3 core principles; an understanding of the socioeconomic determinants of health, behaviour change skills and assessment of and intervention to support the 6 pillars of Lifestyle Medicine. The 6 pillars are; mental well-being, healthy relationships, healthy eating, restful sleep, physical activity and avoidance of harmful substances and behaviours. Key skills include person-centered care, health coaching, social prescribing, and the use of group consultations.
In the UK, the BSLM has over 2,500 members from diverse healthcare backgrounds including GPs, consultants, academics, nurses, health coaches, physiotherapists, dentists, pharmacists, dieticians, social prescribing link workers and more. Thousands of clinicians attend our annual conferences, and our Learning Academy has now accredited hundreds of practitioners in Lifestyle Medicine.
Evidence suggests that over-prescribing and the harm of polypharmacy is an issue for all areas of medicine (5), not just for mental health. The BSLM is committed to raising awareness of this issue and to train clinicians to offer evidenced lifestyle options for all health conditions. The need for action is particularly urgent for the treatment of metabolic diseases (such as obesity, Type-2 diabetes, metabolic liver disease and cardiovascular disease), where lifestyle interventions can treat and even achieve remission without medications.
Policymakers, medical royal colleges, insurers, and bodies such as the General Medical Council and Care Quality Commission need to hear this call for action and understand the critical role of the discipline of Lifestyle Medicine in improving care for patients and the sustainability of healthcare. We need explicit reference to Lifestyle Medicine and the role of clinicians trained in Lifestyle Medicine within medical training curricula, standards, national guidance documents (for example NICE guidance), medical insurance and healthcare policy documents.
Clinicians trained in Lifestyle Medicine understand the wider determinants of health and have the skills to assess and support lifestyle changes that can address patients' mental health needs. In addition, these lifestyle treatments address the upstream causes of many other co-morbid conditions and have wider positive health effects.
Lifestyle Medicine practitioners recognise and support the urgent need for public health and policy action to address the issues of food insecurity, poverty, health inequity and unhealthy environments that are the ultimate drivers of poor mental and physical health. Lifestyle Medicine must be delivered within a healthcare system that also has strong public health and health policy. The BSLM looks forward to working with the APPG to achieve the aim of improving patients’ lives with fewer medications.
References
1. https://prescribeddrug.org/
2. Coventry, Peter A., et al. "Nature-based outdoor activities for mental and physical health: Systematic review and meta-analysis." SSM-population health 16 (2021): 100934.
3. Firth, Joseph PhD et al. The Effects of Dietary Improvement on Symptoms of Depression and Anxiety: A Meta-Analysis of Randomized Controlled Trials. Psychosomatic Medicine 81(3):p 265-280, April 2019.
4. Cooper M, Avery L, Scott J, et al, Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review, BMJ Open 2022;12:e060214. doi: 10.1136/bmjopen-2021-060214
5. https://bslm.org.uk/
6. https://www.gov.uk/government/publications/national-overprescribing-revi...
Competing interests: No competing interests
Dear Editor
I am happy to see this important letter published and I hope the UK may spearhead the long overdue changes in mental health systems worldwide. A shift away from the reductionist medical model and towards socially conscious and responsible psychiatry seems necessary.
Unfortunately, what has been called „marketing based medicine”(1) still in many cases seems to triumph Evidence-Based-Medicine, not only when it comes to antidepressant prescribing. The example of the UK may serve as a wake up call for Global South countries, adopting imported solutions, or for countries such as Poland, where the harsh neoliberal reforms of the early 90s were accompanied by uncritical adoption of Western psychiatric standards, promoted by pharmaceutical companies conquering new markets. The social turmoil of the so called economic „shock therapy” was largely medicalized as individualized psychiatric problems(2).
Currently, the rates of prescription are still much lower in Poland than in comparison with countries such as the USA, the UK or Australia, but are growing at a fast pace. This process has now accelerated further, probably due to the COVID-19 crisis. The Polish National Health Fund, serving a somewhat similar role to the British NHS, is currently spending about 10 times more on subsidized antidepressants than on psychotherapy of depression(3). Psychosocial services are thus largely unaffordable to people suffering from economic and social deprivation who need them the most. What is particularly worrying is that the rising prescription rates for youth are accompanied by a dramatic rise of suicide attempts and completed suicides among people under 18 years old (4,5).
In the public debate, there is little awareness of problems associated with withdrawal symptoms of psychiatric drugs and little acknowledgment of their possible iatrogenic effects, especially long-term, for some people. Awareness campaigns and Key Opinion Leaders repeat the old message of „save, effective and non-addictive” drugs „that save lives”, even though the research on anti-suicidal properties of antidepressants is inconclusive and the opposite effect cannot be excluded(6,7). Hopefully, the countries that have not yet reached British prescription rates can learn from the difficult British experience and avoid repeating the same mistakes.
1. Spielmans GI, Parry PI. From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents. J Bioethical Inq. 2010 Mar 1;7(1):13–29.
2. Stupak R, Dyga K. Postpsychiatry and postmodern psychotherapy: Theoretical and ethical issues in mental health care in a Polish context. Theory Psychol. 2018 Dec 1;28(6):780–99.
3. Stupak R, Dobroczyński B. From Mental Health Industry to Humane Care. Suggestions for an Alternative Systemic Approach to Distress. Int J Environ Res Public Health. 2021 Jan;18(12):6625.
4. NFZ o zdrowiu. Depresja - ezdrowie.gov.pl [Internet]. [cited 2023 Dec 8]. Available from: https://ezdrowie.gov.pl/portal/home/badania-i-dane/zdrowe-dane/raporty/n...
5. Policja P. Statystyka. [cited 2023 Dec 8]. Zamachy samobójcze od 2017 roku. Available from: https://statystyka.policja.pl/st/wybrane-statystyki/zamachy-samobojcze/6...
6. Hengartner MP, Plöderl M. Newer-Generation Antidepressants and Suicide Risk in Randomized Controlled Trials: A Re-Analysis of the FDA Database. Psychother Psychosom. 2019 Jun 24;88(4):247–8.
7. Plöderl M, Amendola S, Hengartner MP. Observational studies of antidepressant use and suicide risk are selectively published in psychiatric journals. J Clin Epidemiol. 2023 Oct;162:10–8.
Competing interests: I'm an Associate of the International Institute for Psychiatric Drug Withdrawal
Dear Editor,
This is not the Christmas edition but a little band width to discuss antidepressants in a simple way might be allowable!
I think most doctors agree that depression has to do with mood. There are downstream effects on cognition, behaviour, sleep appetite etc. However the root cause is low mood. In health mood is usually related to life events. Loss is supposed to be the harbinger of incipient dip in mood. To experience too many losses even small ones and your body thinks "this is going to keep going" and gives up and gets "depressed."
It's hard to say if there was much depression 50-100 years ago or earlier. Asylums were full of all kinds of illnesses. But the death rates from depression were less. Social supports were more extensive and robust and there were no screens, phones or TikTok. We have never before been exposed to so much bad news. Wars, shootings, racism, hatred, greed. We have never been as hamstrung by media, influencers and liars (disinformation). We have never had such small families, loneliness and absent social circles.
Enter big pharma with a mood pill. I'm not saying it's wrong and I see them working all the time but population dependence on mood pills looks like a fantastic marketing strategy but it must be OTT and we must be missing something. It won't help to have silo wars between talking therapists and psychopharmacology and social prescribers. In the absence of addictions, intimidation, work stress I consider the social determinants of health and mood are where we need to focus. The following are key elements:
1. A good night sleep
2. A nourishing diet
3. Friends and family and social contact
4. An occupation suitable to ones skill set
5. Regular exercise appropriate to ones age and health.
Competing interests: No competing interests
Dear Editor
Thanks very much to the campaigners for raising this timely and important issue of prescribing in psychiatry with particular reference to ‘depressive disorder’. This would no doubt be equally applicable to wider psychosocial situations and practices!
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.” Charles Dickens, A Tale of Two Cities.
Over the past couple of decades, we have witnessed profound changes in society from technological advances and geopolitical shifts to climate change and communication pervading all areas of life and with it, peoples’ perceptions, expectations, aspirations and problems!
Pressure to Prescribe:
We are very well aware that there is no pill for every ill. Yet there have been more drug discoveries especially for psychiatric conditions over the past couple of decades than ever before. With this there is a greater expectation and hope with greater increase in people seeking ‘medical’ consultation for ‘psychiatric’ disorders than ever before.
Patience to Persevere:
We have seen great interest in psychosocial-based interventions like Cognitive Behaviour Therapy (CBT), Interpersonal Therapy (IPT), Group Therapy, Aesthetic Therapies like art and music, mindfulness, meditation, etc. We have also seen how these can make big differences in peoples’ perceptions positively and empower them personally. But we also see that there is a need on the part of the person to devote the time, put in the effort, trust, dedication and commitment to progress to achieve transformation which is no doubt longer lasting and possibly almost free of ‘side-effects’.
Paradox of Reductionism:
The brain basis for explanatory models of psychiatric conditions perpetuated in public media and elsewhere puts professionals in paradoxical positions during clinical practice. “If that’s the case, why are you not prescribing?” is a common question, I am sure, many of us have heard. The problem is the more we know about the molecular detail the less we know about their functionality. Many things cannot be explained away simply!
Practice of Holism:
It is easy to see and all accept that there is interdependence and interconnectedness in this world (and possibly the universe). For every condition there is a context and therein the complexity. Thus, we would think that there is the strongest case for the practice of holistic medicine and applying the bio-psycho-social model of conditions and their interventions with thoughtfulness and compassion.
Patient-Professional Partnership:
A clear policy to apply prescribing guidelines whether it is medical or psychological or social can certainly pave the way for working together to work out together. This is a good wake up call!
“Incidentally, it’s easy to write prescriptions, but difficult to come to an understanding with people.” Franz Kafka, A Country Doctor
References:
1. Davies, J., Read, J., Kruger, D., et al. (2023) Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2730
2. Maggiora, G. (2022). Is the reductionist paradox an Achilles Heel of drug discovery?. Journal of Computer-Aided Molecular Design, 36(5), 329-338.
3. Pomey, M. P., Hihat, H., Khalifa, M., Lebel, P., Néron, A., & Dumez, V. (2015). Patient partnership in quality improvement of healthcare services: Patients’ inputs and challenges faced. Patient Experience Journal, 2(1), 29-42.
4. Vogt, H., Hofmann, B., & Getz, L. (2016). The new holism: P4 systems medicine and the medicalization of health and life itself. Medicine, Health Care and Philosophy, 19, 307-323.
Competing interests: No competing interests
Re: Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing
Dear Editor,
As medical students, we were very interested in this topic as we believe that as a society we are at a point where antidepressant prescriptions are becoming increasingly more common.
Socioeconomic factors can potentially influence prescription rates. “In 2022, about 80% of antidepressant prescriptions were in more deprived areas.”(1) We believe that rates of exercise could be linked with the higher rates of prescriptions in more deprived areas. “In the most deprived areas, about 53% of individuals met the guideline requirements in contrast to 68% of individuals in most affluent areas.”(2) The reason we mention exercise in particular is because, in conditions such as depression, we believe that physiologically the problem is due to a “deficiency of hormones such as serotonin, dopamine and noradrenaline”.(3) “Exercise is believed to be useful in replenishing serotonin, dopamine and noradrenaline levels.”(4)
Often with depressive and anxiety disorders, many individuals do not feel comfortable to reach out. This becomes harder to treat as, by the time someone reaches out, their circumstances may have gotten to a stage which is classified as “severe”, and therefore, antidepressants may have to be introduced. “About 70% of young people and adults with mental illness do not receive any mental health treatment from health care staff.” Stigma and discrimination are likely to be significant influences.”(5) We believe we have to invest more in creating platforms and safe spaces for people to reach out without being judged. We also believe it would be a good idea to try and educate the general population about signs of depression and anxiety disorders. We believe that if we can identify depressive and anxiety disorders early, we would be able to treat patients without the use of antidepressants.
References
1. Blush K. NHS releases mental health medicines statistics for 2022/2023 in England [Internet]. NHS Business Services News. 2023. Available from: https://media.nhsbsa.nhs.uk/news/nhs-releases-mental-health-medicines-st...
2. Adult physical activity [Internet]. NHS England Digital. [cited 2024 Jul 31]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/hea...
3. Hasler G. Pathophysiology of Depression: Do we Have Any Solid Evidence of Interest to Clinicians? World Psychiatry [Internet]. 2010 Oct 1;9(3):155–61. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950973/#:~:text=The%20mono...
4. Lin TW, Kuo YM. Exercise Benefits Brain Function: The Monoamine Connection. Brain Sciences [Internet]. 2013 Jan 11;3(4):39–53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061837/
5. Henderson C, Evans-Lacko S, Thornicroft G. Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health [Internet]. 2014;103(5):777–80. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698814/
Competing interests: No competing interests