Is it time for the Scottish Government to be “Realistic” about antidepressants?

Beverley questions whether Scotland is implementing an evidence-based approach to the prescribing of antidepressants.

At a time when the dominant medical model of mental health means prescription rates of antidepressants in Scotland are soaring, should we be concerned by the lack of recognition the Scottish Government gave to the issue in their 2017-2027 Mental Health Strategy? What were their reasons for failing to address what is becoming an ever-increasing problem individually, socially and economically in Scotland?

In 2009/10 Scotland spent £32.2 million on antidepressants.  The Scottish Government reacted by sponsoring a target indicator for NHS Scotland under the title of Health Improvement, Efficiency, Governance, Access to Services and Treatment appropriate to the individual; (HEAT). The objective was to stop the increase by March 2010 and achieve a 10 per cent reduction in future years. The Government was set a proxy measure to focus attention on improving the evidence-based prescribing of antidepressants and improve access to non-drug treatments.

The ‘Heat’ target was unceremoniously reneged on later in 2010; “As our understanding improved, it became clearer that we cannot be sure that implementing evidence-based prescribing behaviour and improving access to non-drug treatments will lead to a reduction in antidepressant usage. Hence, with this better understanding, it would be inappropriate for us to continue with the target.”

Prescribing is the area most affected by evidence-based medicine. Now, prescribers are increasingly expected to back up their decisions with evidence. Evidence-based prescribing should lead to safer and more effective use of medicines. So, why did the Scottish Government choose not to implement evidence-based prescribing for antidepressants? Did the widely available evidence, based on research, present the Scottish Government with an insurmountable task?

The mainstream view that antidepressants and other drugs used in mental health work, is questionable. Evidence-based facts include:

• no known biological causes for any of the mental health disorders apart from dementia and some rare chromosomal disorders
• no chemical imbalances have been proven to exist in relation to any mental health disorder
• antidepressants do not ‘cure’ diseases, and in many cases their mechanism of action is not properly understood
• studies have found that antidepressants have no clinically significant benefit over placebo pills in the treatment of mild to moderate depression
• there has been little research on the long-term outcomes of people taking antidepressants and they can have effects including mental disturbance, suicide, violence, and withdrawal syndromes
• withdrawal from antidepressants can be disabling and cause severe physical and psychological effects which often last for months and sometimes years, sometimes leading to suicide

The failure to address the issue in 2009/10 resulted in Scotland spending £44 million on antidepressants in 2015/16.  With one in three GP appointments now having a mental health component GPs continue to bear the burden of Scotland’s reliance on prescribing antidepressants. GPs are also dealing with patients suffering negative iatrogenic effects of the drugs which often lead to disability claims, health care costs, deaths, and additional psychiatric diagnoses leading to further medication.

In addition, one of the greatest issues facing us is that of dependence on and withdrawal from antidepressants.

In 2016, we attended Stakeholder Roundtable Meetings at the BMA Board of Science, London, to discuss what positive actions can be taken for the future benefit of patients affected by prescribed drugs associated with dependence and withdrawal.

There are no specialist support services in Scotland, with the exception of ‘Recovery and Renewal’, a local independent peer support group based in Helensburgh. In April 2017, Recovery and Renewal launched a petition calling on the Scottish Government to take action to appropriately recognise and effectively support individuals affected and harmed by prescribed drugs associated with dependence and withdrawal, in particular antidepressants and benzodiazepines.

“This represents a significant public health issue, one that is central to doctors’ clinical role, and one that the medical profession has a clear responsibility to help address.” BMA Board of Science, 06 October 2016.

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