Curb antidepressant prescribing to improve mental health, say campaigners
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2873 (Published 05 December 2023) Cite this as: BMJ 2023;383:p2873Linked Letter
Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing
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Dear Editor
Mahase reports that antidepressants are often ineffective and may be associated with significant harms (side effects, addiction, and withdrawal symptoms). Patients with mild and moderate depression are more likely to benefit from lifestyle medicine and psychosocial interventions (BMJ 2023;383:p2873).
Perimenopausal women with depression may also benefit from hormone replacement therapy (HRT). Mental ill-health in the menopause transition is common (1). Pre-existing mental illness often gets worse, and the risk of new-onset depression doubles in women aged 40-50 (2, 3). Suicidal thoughts are up to 8-times more prevalent in perimenopausal women (4). Perimenopausal negative mood symptoms negatively impact women’s ability to work and function – in an American study lost work productivity and medical costs associated with perimenopausal depression were estimated at ten thousand US dollars per woman per year (5) – and may contribute to higher suicide rates in women aged 45 to 49 years in the UK (6).
Perimenopause-associated depression and anxiety can be effectively treated with HRT +/- additional psychiatric support (7, 8). The NICE menopause guideline states that HRT should be considered for the treatment of psychological symptoms that arise in the menopause transition, and states that there is no clear evidence of benefit for antidepressants to ease low mood in menopausal women who have not been diagnosed with clinical depression (9). However, 1 in 3 perimenopausal women who consult their GP with low mood are offered antidepressants (1). Failure to recognise the link between hormone imbalance and mental ill-health causes unnecessary suffering and wastes valuable NHS resources (10). Improving access to HRT would help curb antidepressant use, improve women’s quality of life, and lead to long-term mental and physical health benefits, with cost-saving implications for the NHS.
Dr Sarah Glynne and Dr Louise Newson, GP Menopause Specialists
References
1. The Fawcett Society. Menopause and the workplace. 2022. Available at: https://www.fawcettsociety.org.uk/Handlers/Download.ashx?IDMF=9672cf45-5... . Accessed 9th December 2023. .
2. Bogren M, Bradvik L, Holmstrand C, Nobbelin L, Mattisson C. Gender differences in subtypes of depression by first incidence and age of onset: a follow-up of the Lundby population. Eur Arch Psychiatry Clin Neurosci. 2018;268(2):179-89.
3. Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25(10):1069-85.
4. Usall J, Pinto-Meza A, Fernandez A, de Graaf R, Demyttenaere K, Alonso J, et al. Suicide ideation across reproductive life cycle of women. Results from a European epidemiological study. J Affect Disord. 2009;116(1-2):144-7.
5. Dibonaventura MD, Wagner JS, Alvir J, Whiteley J. Depression, quality of life, work productivity, resource use, and costs among women experiencing menopause and hot flashes: a cross-sectional study. Prim Care Companion CNS Disord. 2012;14(6).
6. Office for National Statistics. Data and analysis from Census 2021. Suicides in England and Wales: 2021 registrations. Registered deaths in England and Wales from suicide analysed by sex, age, area of usual residence of the deceased, and suicide method. Published 6 September 2022. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... . Accessed 9th December 2023. .
7. Behrman S, Crockett C. Severe mental illness and the perimenopause. BJPsych Bull. 2023:1-7.
8. Leonhardt M. Low mood and depressive symptoms during perimenopause - Should General Practitioners prescribe hormone replacement therapy or antidepressants as the first-line treatment? Post Reprod Health. 2019;25(3):124-30.
9. NICE guideline (NG 23). Menopause: diagnosis and management. Published 12 Nov 2015. Last updated 05 Dec 2019. Available at: https://www.nice.org.uk/guidance/ng23/chapter/Recommendations#managing-s... . Accessed 9th December 2023. .
10. Newson L, Lewis R. Delayed diagnosis and treatment of menopause is wasting NHS appointments and resources. BMS 30th Annual Scientific Conference 2021. Post Reproductive Health. 2021;27(4):226-231. doi:10.1177/20533691211036953.
Competing interests: No competing interests
Dear Editor,
I write to ask for a reframe of the letter written by Norman Lamb and his co-authors.
I fully support primary care being able to access alternatives to over-prescribed antidepressants to help people with mental health problems. Not least because primary care prescribing is our hotspot for carbon emissions and the climate emergency is our biggest threat to health. [ref 1] However, what do Norman Lamb and his committee propose GPs working in areas of deprivation and poor mental health with decimated mental health services do instead? Especially given primary care has an ever decreasing proportion of health resource. We know that 80% of determinants of health are social not medical [ref 2]; that years of austerity have had a negative impact on mental health. [ref 3] The letter says "mental health has worsened as antidepressant prescribing has risen". Are GPs working in areas of deprivation and their depressed patients being blamed for the fallout of the austerity policies ?
There is a strong risk that this letter will be used by those wanting to airbrush austerity to do so. Mr Lamb and his Westminster Government colleagues austerity policies have likely resulted in 300,000 excess deaths, including from suicide [ref 4]. This letter is important, but needs to be clear around cause and effect, and honest about inequity of access to alternative measures.
1. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(23)00056-5/fulltext#:~:text=Climate%20change%20is%20the%20biggest,climate%20change%20are%20far%20reaching.
2. https://www.england.nhs.uk/blog/acting-on-the-wider-determinants-of-heal...
3. https://repository.uel.ac.uk/item/885xw#
4. https://lordslibrary.parliament.uk/mortality-rates-among-men-and-women-i...
Competing interests: No competing interests
Dear Editor
Psychiatry is a mysterious medical subspecialty since almost all mental disorders lack concise biological mechanisms. For instance, etiology of depression, arguably one of the most common mental disorders, remains elusive.
For the last two decades, I have always felt a bit uneasy when patients asked for a “scientific” explanation of depression. Then, I carefully clarified that depression is a polygenic and multifactorial disorder without definite pathophysiology. “OK…I can see that depression is complicated. So how are you going to treat me?” asked the patients. “Non-pharmacological intervention should be prioritized before antidepressants as the NICE guideline suggests…” before I tried to explain the possible side effects of antidepressants, often the patients will interrupt me by asking “You meant treatments like counseling and psychotherapy? You are a psychiatrist, aren’t you? A medical doctor? I thought you would suggest something different from a psychologist!”
Of course, I will only prescribe antidepressants to patients who suffered from severe depression refractory to non-pharmacological intervention. I will not prescribe antidepressants merely to prove that I am a real medical doctor. Nevertheless, antidepressants do have a placebo effect that the patients “feel” that they are under advanced medical care. Indeed, placebo effect should be considered when trying to curb antidepressant prescribing.
Competing interests: No competing interests
Dear Editor
I have looked after patients suffering from depression and suffered bouts of clinical depression and anxiety myself and I can report that I found limited efficacy in taking the various anti-depressants: generally change in my circumstances have been the engine for improvement. I also managed to make myself extremely ill by giving up anti-depressants without medical assistance, so I support the essence of this letter.
You point out that housing problems, insecure work and poor diet can contribute to the mental pain of depression and you clearly realise that the millions of pills given out are not helping people who struggle. If you stop giving out pills you must have a ready offer to replace them as the structural change required is not going to happen without a change of government at the very least. A walk in the woods or a knitting group may well help some but inner city dwellers, single people suffering from social isolation or those busy with life and work will not be thanking a GP who suggests a social group without helping someone contact them, or give them the spare time necessary for outdoor pursuits. Leaving a surgery empty handed, with platitudes ringing in your ears from comfortably off general practitioners (who are also very difficult to access) will not help.
If we acknowledge that antidepressants are not the answer, GP services are over-stretched and difficult to access what is your response? I have been a Labour supporter all my life and a socialist too and I know that some senior medical staff are also social democrats who want to see real change, but all too often medics (who are renowned to have had their mouths stuffed with gold to enact the NHS) are not leaders in societal change. If you want to give up your pharmacological remedy you need to do more than write letters.
Competing interests: No competing interests
Re: Curb antidepressant prescribing to improve mental health, say campaigners
Dear Editor,
Where to start? By the time people come to their GP with depression they want some help fairly soon. A prescription is powerful acknowledgment that they are in emotional trouble. That acknowledgment is a powerful therapy on its own. There are other ways to acknowledge but they generally only work with like minds: well educated and reasonably well paid patients. CBT within the next week might be a better option for a limited number of patients.
The rise in prescribing suggests something else. There must be a cultural problem at work there. That toxic mix of what the media feeds us, what is a successful life, our behaviour towards each other, our expectations about life in general and all the milestones it will involve, including the inevitable decline and the ups and downs of relationships.
It may even be bigger than that. We may have peaked as a species some decades ago and we are all declining emotionally as we are consumed by our own cleverness and overdevelopment. We have gone through too many one way doors. Social improvement and more equal societies may stem the decline but a decline it will remain. If this is true there is nothing we can do. Acceptance may be the most effective therapy of all.
Competing interests: No competing interests