“What is treatment resistance in Psychiatry?”

The above editorial “What is treatment resistance in Psychiatry?” features in the current edition of World Psychiatry and has generated considerable discussion on social media.

Ten months ago this “News” feature “Treatment resistant depression: what are the options?” was published in the BMJ, it also generated a number of responses:

The following rapid responses have been published in the BMJ (in date order):

19 December 2018

Edward M White, Global Solutions Architect (IT), Pewsey, Wilsthire

Re: Treatment resistant depression: what are the options?
As a lay person who has suffered from debilitating withdrawal from venlafaxine, I find this article deeply worrying. The fact that patients are being subjected to a merry go round of medications in a primary care setting, where pressures on GPs time is huge, is probably the worst outcome for someone suffering from a depressive illness. As I’m sure many of your readers would agree, the second generation AD medications have some horrible side effects and people can easily be put off by them. Having to try drug after drug without success and being switched between medications in an often haphazard manner (this happened to me, so I speak from experience), is enough to push many suffers away from the system all together. I found the process to be a frightening one.

Whilst I cannot entirely blame doctors for this, they must shoulder some of it. That said, like many modern ‘systems’ primary health care is not well set up for dealing with this issue. However, secondary psychiatric services are even more pressed due to constant government cuts and other factors.

These time and funding constraints are also compounded by the inability of psychiatry to see the flaws in the drugs administered. Many chronic sufferers will be drugged and released from the system without further help. The drugs are not designed or tested or in any way proven for long term use, which is now resulting in patients becoming long term trial participants with no one collecting the data. I am one of them and I worry constantly about how I am going to get off these drugs safely. Granted, they provided help in the short term, but I should not have been left on them long term by my GP. I feel mislead and betrayed by that process and there are many thousands more in the same or worse situation than me. It is only my own tenacity that prevents the psychiatric service I was referred also discharging me whilst taking unneeded medications. I am insisting they see me safely off the drugs as well. How long their patience will last, I don’t know.

I am sure there are many desperate long term sufferers who would be willing to try ketamine or psilocybin, but they too are psychotropic and recreational drugs with no long term use data. What is really needed are proper services to support sufferers with talking therapies, dietary advice and investigative options to get to the root cause of their illnesses. More drugs are not the real answer.

Yours faithfully
Dr Ed White

Competing interests: No competing interests


20 December 2018

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology, Thessaloniki, Greece

Re: Treatment resistant depression: what are the options?
In a meta-analysis of 28 studies, 61% of patients treated with antidepressant pills still suffer from clinical depression after little more than a year “relapse–recurrence rates with pharmacotherapy of 61% (3.9% per month) over a mean of 68 weeks”

NICE’s definition of non responders greatly underestimates the real number of patients not helped by antidepressants.

Reference
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2630051/

Competing interests: No competing interests


21 December 2018

Marion Brown, Psychotherapist and Mediator (retired), Helensburgh

Re: Treatment resistant depression: what are the options?
Dr Ed White makes some very pertinent points in his response.

We are hearing that patients are experiencing just exactly what this BMJ News piece – and Dr Ed White – describes.

Perhaps the problem is with the antidepressants – not working and/or making people more ill and developing further troublesome symptoms ‘needing’ other medications. And perhaps the experts are not taking any notice of the growing clamour from the voices of patient experience? The advice that the professional ‘experts’ are offering to GPs (and summarised in this BMJ news article) does seem to be a recipe for lifetime illness and polypharmacy. Surely this goes against all common sense?

A very important patient-led event – raising awareness of these very issues – took place at the Wales Senedd on Tuesday 11 December. Full details of this have now been published here.

Competing interests: No competing interests


21 December 2018

Noel Thomas, retired/ part time GP, BronyGarn, Maesteg, Wales

Re: Treatment resistant depression: what are the options?
At a guess (which others may dispute), Dr Ed White is probably speaking up for thousands, or tens of thousands, of people in the UK, whose lives have been made more miserable by antidepressants.

After a few decades of SSRI use, the data behind the trials, reluctantly revealed, show a definite excess of deaths from suicide in younger people, as well as a failure to show any definite consistent benefit in alleviating depression, compared to psychological therapies. The resulting uncertainty has been noted and referenced in your pages by numerous readers. (1,2,3)

The serious side effects and the problems that many people face when trying to stop SSRI drugs are insufficiently understood by doctors, and hence may not be explained to patients who are prescribed these drugs. This is contrary to the fully informed consent process that is obligatory for UK doctors to follow, since the Montgomery case. (4)

This area of practice was discussed last week at the Welsh Senedd in Cardiff, where Dr David Healy was the main speaker. Healy’s presentation is essential viewing for each and every doctor who prescribes anti depressants. (5)

1 https://www.bmj.com/content/360/bmj.k1073/rr-0
2 https://www.bmj.com/content/356/bmj.j249/rr
3 https://www.bmj.com/rapid-response/2011/10/31/full-disclosure-ssri-data
4 https://www.themdu.com/guidance-and-advice/guides/montgomery-and-informe…
5 https://www.madinamerica.com/2018/12/antidepressant-dependence-welsh-gov…

Competing interests: No competing interests


21 December 2018

Fiona H French, Retired, Member of online patient support community for prescribed drug dependence, Aberdeen, Scotland

Re: Treatment resistant depression: what are the options?
As a member of the online prescribed harmed community, I read with interest the article by Greta McLachlan on treatment resistant depression. I was prescribed antidepressants for 35 years and derived little benefit from any of them. I believed that my “depression” was somehow untreatable and therefore something to be endured. I lost hope many years ago. I was always too frightened to come off the drugs but at age 62 I finally became drug free and feel mentally stable for the first time since the age of 20. In my case, the underlying cause of decades of “depression” was undoubtedly a benzodiazepine also prescribed to me since the age of 20. I was unaware this was the cause of my ongoing “mental health” problems. Would I have been classed as “treatment resistant” or as someone who had been treated successfully? I suspect it would have been the latter.

The article on TRD states “NICE’s definition would mean 2.7 million people in the UK have treatment resistant depression (between 10% and 30% of people with depression), an unmanageable number for the NHS’s psychiatric services.” Yet, MIND estimates that 3.3 in 100 people suffer from depression in England, this equates to a total of 2.2 million sufferers across the UK. (1) In February 2018, The Times reported that “about two million people in Britain are thought to suffer from depression, yet studies suggest that only a sixth get the help they need.” (2) This would suggest that only 333,000 are getting the help they need, yet there are at least 9 million patients on antidepressants in the UK. I wonder which definition of depression is being used in these varying estimates and how many of the 9 million patients on these drugs never really needed them in the first place.

I now know that SSRI antidepressants have very limited efficacy and if I had been informed of that years ago I would have realised that the drugs were the problem and not my mental health. Perhaps the real underlying cause could then have been identified. The difficulties of trying to taper off these drugs are immense and for many patients no warnings were given that this could in fact be the case. This coupled with the limited benefits means that for many patients the risks simply aren’t worth it. As Dr Des Spence states “Antidepressants are a problem for millions. The truth is, antidepressants lack efficacy, have a high placebo response and risk a long-term form of dependence.” (3)

(1) https://www.mind.org.uk/information-support/types-of-mental-health-probl…

(2) https://www.thetimes.co.uk/article/more-people-should-get-pills-to-beat-…

(3) https://bjgp.org/content/66/652/573

Competing interests: No competing interests

2 Replies to ““What is treatment resistance in Psychiatry?””

  1. Thank you.

    I would encourage anybody to comment. I would understand if those making comments may prefer to be kept anonymous. As long as comments are constructive and respectful I am happy to post anonymous comments. The best way to do this is by e-mailing me peter@holeousia.com

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