The doctor
Are antidepressants over prescribed? It's a tough question. In 2003 there were 19m prescriptions issued for just one class of drug, called SSRIs. But depression is a common and serious illness, affecting one in 15 women and one in 30 men over the same period. The new guidance on antidepressants from the National Institute of Clinical Excellence may cause some patients to panic, but it represents a far more realistic and grown-up expression of the limits of medicine than we've had in the past.
In essence, antidepressants are not, and never have been, a panacea. They help many patients with moderate or severe depression in the short term but are more effective if used in conjunction with counselling or cognitive behavioural therapy - "talk and tablets". Alas, getting good therapy within a realistic time frame on the NHS can be extremely difficult, so most patients with depression end up on tablets alone, save for the occasional brief consultation with their GP.
Given that depression is often heavily rooted in what's going on around us, it's hardly surprising that drugs alone are not the answer. How can readjusting your brain chemistry ever completely sort out the pain of bereavement or unemployment or divorce? The aim is for the antidepressants to give you the stamina to try to come to terms with the circumstances that surround the depression, not to cure it.
Depression, as those who've had it a while will testify, is a chronic illness. Drugs can be very effective at hauling you out of one black hole of despair, but there's always a chance you'll fall down another in the future.
That said, it is extremely rewarding for me as a GP to see patients recover from a bout of depression. My father suffered from the illness in Australia in the 60s when real men didn't get depressed. He wasn't diagnosed and he took his life when I was seven. For much of the last 20 years, doctors have been told that we've been under diagnosing depression, and the suicide rate for young men especially has gone up. So it's confusing for us to be told we may now be over-treating the condition.
The new recommendations state that drugs shouldn't be used as a first choice for mild depression, but are appropriate for moderate or severe forms of the illness. Although we're guided by the duration of symptoms and whether physical signs such as poor sleep, constipation or loss of appetite are present, a lot depends on the patient's subjective view of how tired, hopeless, guilty, apathetic or suicidal they feel.
No one likes using strong drugs unless indicated, but I suspect that with depression, we err on the side of prescribing when we could occasionally wait and see. The body has a remarkable capacity to heal itself, if given time and space.
So what should you do if you're on antidepressants and not sure whether you need to be? If you've got the concentration to read this article, you may be on the road to recovery. But don't stop any drugs suddenly; the rebound effects can be very unpleasant.
Chat with your GP and if you think the time is right, cut the dose gradually. If you're not sure whether you need to start treatment, keep a symptom diary over a few weeks to show your doctor. But if you're too knackered to do this or have any thoughts of harming yourself, get help now.
PH
The patient
Now, thanks to the guidelines issued to GPs yesterday by the government's medicines watchdog in a bid to cut down the number of antidepressants prescribed in the UK, patients with "mild-to-moderate" depression can look forward to being told that the answer to the symptoms they are presenting is to exercise more or sign up for a costly course of private psychotherapy or counselling that they may not be able to afford.
These absurd, unrealistic guidelines instantly raise several questions. How is an overworked GP meant to differentiate between mild-to-moderate depression and serious depression in a single 10-minute appointment? Is there such a thing as mild or moderate depression? If a patient feels bad enough to seek medical help, then surely those symptoms need addressing? And lastly, since most mild-to-moderate depression, if left untreated, eventually snowballs into serious depression, then won't these guidelines lead to a soaring incidence of suicide attempts, and therefore further burden to the NHS?
I can see that the guidelines are trying to dissuade a patient who is having a bad time circumstantially (divorce, job loss) from turning up at their GP's office and demanding a prescription for Prozac. But, in trying to address one small problem area, both the Medicines and Healthcare Products Regulatory Authority (MHRA) and the National Institute for Clinical Excellence (Nice) seem to have taken a sledgehammer to the entire realm of antidepressant prescription.
Bearing the brunt of these wildly generalising reports are people such as myself, for whom antidepressants are the difference between life and death, a "normal" life and a severely compromised one.
Seeking help for depression and anxiety can be a humiliating, embarrassing experience. For instance, very few sufferers that I know, including myself, feel comfortable admitting to their GPs that they feel suicidal. We tend to say "no" for fear of being sectioned. How can these guidelines possibly work when so many "serious" cases of depression are presented as "mild-to-moderate"? Having, on occasion, had enormous difficulties getting an antidepressant prescription from a GP when I knew I needed one (I was told that my symptoms were "not serious enough" - months later I was suicidal), I think these reports will force GPs to play Russian roulette with patients' lives.
The MHRA's guidelines about specific antidepressants must have scared a lot of people yesterday. They've now decided to demonise "the antidepressant venlafaxine [Efexor]" (which I've been taking for two-and-a-half years and have found mostly invaluable).
"The CSM [Committee on the Safety of Medicines] has considered the balance of risks and benefits of Efexor because of concerns about cardiotoxicity and toxicity in overdose. CSM recommended that treatment with Efexor should only be initiated by specialist mental health practitioners, including GPs with a special interest, and there should be arrangements in place for continuing supervision of the patient."
Like most patients across the UK taking Efexor, I have no idea what cardiotoxicity is, only that it sounds ominously fatal. Rather unhelpfully, the MHRA concludes: "Patients currently doing well on treatment with Venlafaxine can continue to the end of their course." If I'm taking an indefinite maintenance dose where does that leave me? Cardiotoxic but able to live a normal life?
Like NICE's guidelines for the treatment of self harm, published last summer, these vague, ill considered guidelines smack of scaremongering and stereotyping and completely fail to consider the role of the patient, surely the most important person in the equation?
NJ
