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
- James Davies, associate professor of medical anthropology and psychology1,
- John Read, chair2,
- Danny Kruger, member of parliament and chair3,
- Nigel Crisp, co-chair3,
- Norman Lamb, former member of parliament and minister for care and support4,
- Michael Dixon, chair5,
- Sam Everington, general practitioner, vice president, deputy chair56,
- Sheila Hollins, emeritus professor of psychiatry, independent life peer78,
- Joanna Moncrieff, professor of critical and social psychiatry9,
- Bogdan Chiva Giurca, global lead and clinical lead10,
- Chris van Tulleken, associate professor9,
- Guy Chouinard, professor of clinical pharmacology11,
- Michael Dooley, treasurer5,
- Anne Guy, member, secretariat3,
- Mark Horowitz, clinical research fellow in psychiatry12,
- Peter Kinderman, professor of clinical psychology13,
- Lucy Johnstone, consultant clinical psychologist14,
- Luke Montagu, co-founder15,
- Antonio E Nardi, professor of psychiatry16,
- Sarah Stacey, co-founder17,
- Martin Bell, head of policy and public affairs18,
- Andrew Tresidder, clinical lead19,
- Jo Watson, psychotherapist20,
- Stevie Lewis, member21,
- Marcantonio Spada, professor of addictive behaviours22,
- Rupert Payne, professor of primary care and clinical pharmacology23,
- Naveed Akhtar, co-chair and council member245,
- Christian Buckland, chair25,
- Jon Levett, chief executive officer25,
- Sue Whitcombe, chair26,
- Laura Marshall-Andrews, general practitioner and author27
- 1University of Roehampton, London, UK
- 2International Institute for Psychiatric Drug Withdrawal, London, UK
- 3Beyond Pills All Party Parliamentary Group, Houses of Parliament, London, UK
- 4UK Government
- 5College of Medicine, London, UK
- 6BMA
- 7St George’s, University of London, UK
- 8House of Lords, London, UK
- 9University College London, UK
- 10National Academy for Social Prescribing, London, UK
- 11McGill University, Montreal, Canada
- 12North East London NHS Foundation Trust, UK
- 13University of Liverpool, UK
- 14Bristol, UK
- 15Council for Evidence Based Psychiatry, London, UK
- 16Federal University of Rio de Janeiro, Brazil
- 17College of Medicine Beyond Pills Campaign, London, UK
- 18British Association for Counselling and Psychotherapy, UK
- 19Medicines Management NHS Somerset, UK
- 20Worcestershire, UK
- 21Lived and Professional Experience Advisory Panel for Prescribed Drug Dependence, UK
- 22London South Bank University, UK
- 23University of Exeter, UK
- 24Integrated Medicine Alliance, UK
- 25UK Council for Psychotherapy, London, UK
- 26Division of Counselling Psychology, British Psychological Society
- 27Brighton, UK
- jp.davies{at}roehampton.ac.uk
We, a group of medical professionals, researchers, patient representatives, and politicians, call for the UK government to commit to a reversal in the rate of prescribing of antidepressants.
Over the past decade, antidepressant prescriptions have almost doubled in England, rising from 47.3 million in 2011 to 85.6 million in 2022-23. Over 8.6 million adults in England are now prescribed them annually (nearly 20% of adults),1 with prescriptions set to rise over the next decade. In addition, the average duration of time for which a person takes an antidepressant has doubled between the mid-2000s and 2017, with around half of patients now classed as long term users.2 Scotland, Wales, and Northern Ireland have similar rates of antidepressant prescribing.
Rising long term use is associated with many adverse effects, including weight gain, sexual dysfunction, bleeding, falls, and poorer long term outcomes for some. Withdrawal effects 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.3
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.4 Questions remain about the extent to which poor outcomes are fuelled by such adverse effects and the poor efficacy of antidepressants for many groups. Multiple meta-analyses have shown antidepressants to have no clinically meaningful benefit beyond placebo for all patients but those with the most severe depression,5 which is why guidance from the National Institute for Health and Care Excellence states that they should not be routinely prescribed as first line treatment for less severe depression, while still respecting the importance of shared decision making.
Despite this, rates of prescribing to patients with mild and moderate depression remain high. One study of UK primary care data found that 69% of diagnosed depression in people aged 65 and over was of mild severity.6 A study of US National Health and Nutrition Examination Survey data found that 26.4% of patients in the sample who were taking antidepressants reported mild depressive symptoms.7 Another UK study showed that 58% of people taking antidepressants for more than two years failed to meet criteria for any psychiatric diagnosis.8
There are now evidence based objections to prescribing antidepressants for people with chronic pain, where efficacy is very low,9 alongside evidence of disproportionate prescribing to women, older people, and those living in deprived areas. This raises questions about the extent to which we are wrongly medicalising and medicating the effects of disadvantage and deprivation.
As well as the human costs of unnecessary antidepressant prescribing, there are now substantial unnecessary economic costs being incurred by the NHS in England of up to £58m annually10—money that could be better spent boosting non-pharmacological provision. This problem has been recognised by the NHS in its National Medicines Optimisation Opportunities 2023-24 statement.11
We think a reversal in the rate of antidepressant prescribing can be achieved by following through with various public health recommendations, in line with the NHS National Medicines Optimisation Opportunities 2023-24. These include stopping the prescribing of antidepressants for mild conditions for new patients; adhering to the 2022 NICE guidance on safe prescribing and withdrawal management, including properly informed consent and regular review of harms and benefits; funding and delivering local withdrawal services integrated with social prescribing, lifestyle medicine, and psychosocial interventions; including the reduction of antidepressant prescribing as an indicator in the NHS Quality and Outcomes Framework; and funding and delivering a national 24 hour prescribed drug withdrawal helpline and website.
Finally, we hope other countries with high levels of antidepressant prescribing will also commit to a reversal in prescribing rates.
Footnotes
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. NL is chair of the South London and Maudsley NHS Foundation Trust and chair of the National Oversight Group HOPE(S) Programme Board, a clinical model developed by Mersey Care NHS Foundation Trust to reduce the use of long term segregation sometimes experienced by autistic adults, adults with a learning disability, and children and young people; paid adviser for Kooth, the UK’s largest provider of NHS commissioned digital mental health services, and Alertacall, a housing management and digital telecare company that works to improve health and safety, with repairs reporting and to detect changing needs. 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 All-Party Parliamentary Group for Prescribed Drug Dependence. 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. LM is co-founder of the Council for Evidence Based Psychiatry and secretariat member of the All-Party Parliamentary Group for Prescribed Drug Dependence. JW is founder of A Disorder for Everyone. RP receives research funding from the NIHR for research into polypharmacy and deprescribing. SW is current chair of the British Psychological Society Division of Counselling Psychology, for which she receives a small annual remuneration of less than £4000. All other authors have none to declare.