RSM Health Matters Podcast: Episode 1 – Antidepressants

RSM Health Matters Podcast: Episode 1 – Antidepressants, Antibiotics and the Gender Pay Gap

26th April 2018

Kaji Sritharan (KS), Professor Sir Simon Wessely (SW), Professor Clare Gerada (CG)

[This is a transcription of the first 14 minutes of this half hour episode]

This is RSM Health Matters a podcast brought to you by the Royal Society of Medicine. Hello, I am Kaji Sritharan and welcome to RSM Health Matters. In each episode I will be joined by Professor Sir Simon Wessely, President of the Royal Society of Medicine and Past President of the Royal College of Psychiatrists, and Professor Clare Gerada, GP and Past Chairman of the Royal College of GPs, to discuss and debate the main issues affecting medicine today. In this podcast we will be discussing two commonly prescribed medications, and those are antidepressants and antibiotics.

KS: Clare, in 2016 there were 64.7 million prescriptions of antidepressants in England, more than double the 31 million in 2006. Why is antidepressant prescribing on the increase?

CG: It is actually a complex question because some of it might be an artefact, the way we are advised now to prescribe antidepressants means that we might actually be counting more prescriptions than we were a decade ago. So, for example a decade ago we might give three months at a time, we might give higher doses for three months, now we are more likely to give a month or two weeks. So I think it is probably an artefact, nevertheless I do think we are prescribing more antidepressants and I think quite rightly. We are encouraged and we certainly are screening more patients for depression, so patients for example with chronic complex diseases, patients with diabetes, most consultations we will ask them about their mood. Any patient that has got three or more chronic diseases we will automatically ask about their mood. So I think we are identifying patients much better than say we used to do about decade ago. So much of this I think is appropriate prescribing by GPs. I also think to a certain extent there is a certain sense that, certainly where I sit in General Practice ,of more patients are coming with low mood, more patients with depression. I also think it is a stigma issue, I think we don’t have John Humphries on the Today programme banging down ‘we are prescribing too much insulin’ but nevertheless, once a year, when the prescribing figures come out we have this soul-searching why are we prescribing too much of this medication which I think works, I think saves lives, and I think make people, enables people to live normal lives.

KS: Simon, if I can come to you do you believe that mental health is on the increase?

SW: For really, or during all our lives the prevalence of most psychiatric disorders have remained very stable, so for as long as we have been doing big studies in the population, there has been very very little change in all the disorders that we study, which is kind of contrary to every single generation always thinks that things are getting worse. So it has been a standard thing that mental health is getting worse, that mental illness is more common, and so on and so forth. But actually it is not been true until very recently, only in the last decade have we actually seen a true increase in rates and I don’t mean people going to see their doctors which has obviously been increasing, but an actual real increase, and that has just been in one group and that is 18 to 24 year old girls or women, and it has been depression and anxiety and we will probably see the same in a younger group as well when that study comes through. That is the first change we have seen. So for women for example from 18% six years ago it is now 24% that have anxiety or depression.

KS: And what are the factors contributing towards that?

SW: Aha, I mean the truth is everybody has an idea, very few people know. In fact I would say that nobody knows. There are multiple factors: its to do with the economy, it might be due to changes in parenting styles, lots of people blame social media, it could be due to bullying, it could be due to huge student fees, all sort of things. I think is the truth is nobody knows. But we have seen a true increase. That is correct.

KS: And are antidepressants the right answer?

SW: Well it depends on what you mean is right? They are one answer and they are often very helpful. They are not the only answer and I don’t think anyone has ever argued that they are. And lets be clear what we know. There was a big piece in the New York Times by Ben Carey, a very good reporter, who starts out by saying antidepressants are effective, okay we know that. We know that in the short term they certainly help reduce episodes of depression. We know that in the longer term they help reduce relapse. They are much safer than the previous old alternatives that we have used in the past. So yes, they are good drugs and that is why they are used widely. But they are also pointing to problems.

KS: So are you talk about longer term use and that they are effective in reducing relapse. Are you advocating long term use of antidepressants in all patients?

SW: No one is advocating long term use of antidepressants in all patients, any more than anyone is advocating long term use of antibiotics. So, first in the short term they are effective; we now know that most people you should treat for 6 months if they have responded. We also know now for up to one and two years, if you compare them with placebos, you get lower rates of relapse on antidepressants. Okay. We know also out there that many many people taking antidepressants, possibly listening to this podcast, are people who have found that even for far longer periods antidepressants keep them stable and allow them to live normal lives. So that’s clear. I think we are more aware of the problems of what happens when you stop, or discontinuation and some of the symptoms that you’ll develop after that. I think that is probably because, as with all drugs, we always know more about them in the short term because in order to get a drug on to the market you have to do huge studies to show that they are effective in the short term. That is proven beyond doubt. We know less about long term: (a) because it is long term, and (b) because industry that originally funds these studies gets less interested as they go off patent and there is not much money to be made.

KS: Okay, what are the side effects that you see from withdrawing medication?

CG: There is a lot of controversy at the moment about effects of withdrawing from antidepressants and I have read the literature and I have seen this study and I do talk to people who claim that their lives have been ruined by antidepressants. Personally, as a GP of 26 years in the same practice and someone that trained in mental health, so I’ve seen, probably about 1 in 2 of every patient I have seen has had a mental health problem, so 50% of every single of the tens of thousands of patients I have seen has been with a mental health issue, and I can count on one hand the number who have gone on to have long term problems withdrawing from antidepressants or problems coming off antidepressants. So, far, far, far more patients have problems coming off benzodiazepines which in the early days many of my patients were on. Now, I am not disputing that some patients do have problems, absolutely not. But I am just concerned that every time we focus on the withdrawal what happens in my consulting room patients are ashamed to take antidepressants, and worse still, ashamed to admit that they are depressed because they will be labelled as somehow weak willed. So I think it is a very difficult issue and one we that we need to be very careful.

KS: But there have been quite high-profile cases in the news which either talk about being suicidal whilst on antidepressants or struggling to come of antidepressants.

CG: Yeah, and Kaji, what I warn all my patients: so if you take an antidepressant the first two to three weeks you will wonder what on earth the doctor has done. They have given you a medication that raises the level of anxiety, so the first two weeks of taking of starting an antidepressant you feel hyper-alert and patients describe this agitation and worsening of suicidal thoughts. So you have to counsel the patient about that you have to say, bear with it, it takes time, it takes about a month for the antidepressant effect to kick in and two weeks for that anti-anxiety effect. But then, and you have to see this, I run a service for sick doctors, and okay, its mentally ill doctors. They come to see me and they have ruminations following a complaint that destroy them, destroy the ability to work, ruminations about that they are going to end up in prison, or that they are the worst person in the world, they can’t focus. You see similar patients with post-natal depression, ruminations that they are the worst parent in the world, that they would be better off dead. They start antidepressants and those ruminations stop. It doesn’t sort the world out, it doesn’t stop their money problems or their complaint issues. So, antidepressants I think we should focus on the positive. Of course we should talk about the side-effects, but what I worry about, and I see this because I think it is a stigma issue is we tend to focus on the negatives all the time.

KS: Simon, is that your experience as well?

SW: Like most psychiatrists I don’t have the same experience with antidepressants that GPs do. Most depression is treated in this country by GPs and not psychiatrists. I think that Clare is basically right. And there is several points one can make on that. The first is that we all agree that the number of antidepressants being prescribed has been increasing, so up to 66 million this year in the UK, and in the USA has gone up by 30 million over a ten year period. Now if there was even a small association with either suicide or homicide with that scale of increase, you couldn’t, even a really small association, you couldn’t help but see it in suicide rates and homicide rates which are pretty tightly measured. And we haven’t seen. So I think some people have extrapolating from the side effects, that Clare has been talking about, agitation, restlessness etc and then making a very big jump into that is sometimes seen in people who have committed suicide or indeed committed homicide, that is the kind of things they may report before hand, but there is a huge gap in-between., and its a big leap there. The second point to make is the issue of addiction. Addiction is pretty well described and most of the population know what addiction is. But antidepressants are not active in the classic sense of addiction. You can’t sell them out on the street. There is no market for antidepressants. You don’t get a high from taking them, that’s one of the problems actually it takes weeks for them to have their effect. You don’t crave for them. You don’t do behaviours that go with people who are addicted to heroin, cocaine, and indeed benzodiazepines or opioids that are prescribed by doctors. So I think addiction isn’t the right issue to talk about. I think it is true, I think it is a fair point that withdrawal symptoms probably have been underestimated, they can be confused with relapse of the illness, which certainly happens as well. But overall, antidepressants save lives. Most people successfully come off them without difficulty. I think probably we have overlooked those who do have difficulty, and I also think we really don’t do much for them, that’s absolutely true. When I was President of the College we did support more funding for helplines for those who have problems with withdrawal and prescribed drugs. I think that is a perfectly reasonable thing to do.

KS: One last question on this topic for you Simon, what advice would you give a GP contemplating starting a patient on antidepressants?

SW: As Clare has said, the indications – its much like antibiotics, we shouldn’t be prescribing antibiotics for short term illnesses, viral illnesses etc – we shouldn’t be prescribing antidepressants for short term anxious or periods of sadness, bereavement etc and the vast majority of doctors don’t do that. We will be doing it for clinical indications not emotional distress. Any more than we should be prescribing antibiotics for sore throats, some will, some psychiatrists will, but most won’t. The second thing is, going right back to where you started, there is no question at all I don’t think that anyone in my profession or Clare’s profession, or anyone thinks that antidepressants are the answer to depression. They are part of it. If I get depressed I want to have them. I would take antidepressants, I certainly would. I’d also want to have psychological treatments as well.

CG: I do use antidepressants for patients who aren’t depressed who are very very anxious, who are plagued with ruminations. I do also use antidepressants in my sick doctor service who might have had referral to the regulator because I know that they are going to get depressed. Unfortunately because there is so much hype we wait till the biological symptoms of poor sleep, anhedonia, weight loss or weight gain, rather than start to think well actually can we start them at an early stage to prevent depression. This is where I really would like the psychiatrists to move away from the fear, which has been, I think propagated by the media and certain people, to actually say is there a space for antidepressants in preventing depression when we know there is a very high chance that depression will happen.

KS: Simon, a very short comment in return. What are your views of prophylactic use of antidepressants?

SW: Well I think it is the same answer I would give whenever I am asked a question I do not know the answer to, well that is fine but you will need to come up with some pretty good evidence for that. I am not aware that it exists, but I would be delighted to see good trial evidence on that issue. Our reputation in the prevention of mental disorders is not very good, we are much better at treating disorders than preventing , that is why we don’t advocate screening for depression for example because lots of studies have shown it does not work. But as I say, I am the boring boffin here.

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