Antidepressants are being used as stopgaps: patients need a range of therapies now

GPs need shorter waiting times for their patients, more training and a greater range of psychological therapies to refer to so that antidepressants are no longer used as a ‘stopgap’.

Antidepressants are being used as stopgaps: patients need a range of therapies now

Timely, appropriate treatment can make all the difference to people with mental health conditions. Antidepressants are one of the treatment options available and NHS Digital data reveal that pharmacists in England are now dispensing almost double the number of these drugs than a decade ago — 70.9 million prescriptions for antidepressants in 2018, compared with 36 million in 2008. And this number is rising[1]
.

It is difficult to know, however, if changes in the way prescriptions are being issued — such as carrying out more regular medication reviews before giving another prescription — are skewing these numbers. We need to better understand how many people are taking antidepressants and for how long, and whether they are receiving other treatment alongside their medicines, as recommended in guidance from the National Institute for Health and Care Excellence (NICE).

However, antidepressants are not the only option. At the mental health charity Mind, people tell us that it is often a combination of different treatments and techniques that help them best manage their symptoms. In addition to, or instead of medicine, many people benefit from talking therapy, exercise, a socially prescribed activity such as arts therapy — or a combination of some or all of these. These treatments must be made available to all who need them.

No choice but to medicate

Medicines must not be used as a ‘stopgap’ in lieu of non-pharmacological treatments

Pharmacological medicines work for millions of people — the Royal College of Psychiatrists suggests that around 50–65% of people who take them feel they benefit from doing so[2]
. However, some people report feeling worse before they get better. Others experience adverse side effects, such as suicidal thoughts and desire to self-harm, that are more severe than the symptoms of the condition they are trying to treat[3]
.

Such medicines must not be used as a ‘stopgap’ in lieu of non-pharmacological treatments. Talking therapy, for example, when undertaken alongside antidepressants can be more effective than drug therapy alone, even in treatment-resistant depression[4]
.

Withdrawing from antidepressants can be difficult too. In September 2019, NICE updated its guidance — which formerly suggested withdrawal symptoms were usually “mild” and “self-limiting” over the course of a week — to clarify that there can be “substantial variation in people’s experience”, and that symptoms can persist for months and be “more severe for some patients[5]
”.

There must be a wider range of training made available in mental health settings

Therefore, it is crucial that our healthcare system can offer a choice of treatment. For most of us, the GP is the first port of call when we are unwell and we are often prescribed medicine as a result. But, too often, people with mental health conditions lack access to non-medical treatment because GPs — strapped for time and resources — feel they can offer patients few alternatives[6]
. We hear from many GPs who feel they must prescribe antidepressants because they need to do something, there and then, for the person sitting in front of them, and that they have little control over helping patients with their mental health in the long term.

There is also a serious issue with the lack of appropriate mental health training for primary care professionals, meaning they often lack knowledge of the range of ways to support people with mental health conditions. There must be a wider range of training made available in mental health settings for GPs so that they are equipped and confident to provide the best care for anyone struggling with their mental health.

Getting patients talking

In 2008, NHS England launched the Improving Access to Psychological Therapies (IAPT) programme to help get people into talking therapy. The programme has been transformative: NHS Digital suggests that, in 2017–2018, 89.4% of referred patients were seen within six weeks for their first appointment (usually an assessment) and 99% waited less than 18 weeks to start treatment[7]
. However, many people are facing long waits between appointments, even though we know patients must have consistent sessions for treatment to be effective.

A quarter of the people who are referred to IAPT do not take up treatment

Making matters worse, if a patient requires a less common type of therapy for a more severe and enduring mental health condition, they may have to wait months or even years between referral and their first session[8]
. In December 2018, the British Medical Association made Freedom of Information requests to 183 clinical commissioning groups about waiting times for specialist talking therapies, such as dialectical behavioural therapy, cognitive behavioural therapy, family therapy and dynamic psychotherapy[9]
. Of the 47 that responded, 22 had no records of these waiting times; however, the ones that did reported that 3,700 patients waited more than six months for their therapy to start, and 1,500 patients waited longer than a year[9]
.

Aside from issues with waiting times, the IAPT model is not perfect — only half of people who are referred to IAPT recover, and it has been criticised for pulling resources away from other services for more severe mental health conditions[7],[10]
.

Alternative therapies

A quarter of the people who are referred to IAPT do not take up treatment, and a third of those who do drop out before the end of treatment[11]
. The model was not designed and rolled out with everyone in mind.

Particularly, the IAPT model does not consider the impact of race or social determinants in mental health, and it is concerning that people from black, Asian and ethnicity minority (BAME) backgrounds seem to face more difficulties in accessing, staying in and responding to the treatment it provides[8]
.

Black people are less likely to be offered talking treatments and more likely to be given medicine to manage their mental health

We know that it can be difficult for people from BAME communities to be referred for therapy in the first place; for example, there is evidence to suggest that black people are less likely to be offered talking treatments and more likely to be given medicine to manage their mental health[12]
.

It is crucial that GPs and other healthcare providers can offer culturally relevant support: this includes making the right referrals, rather than relying on medicines for certain demographics. Services are often seen as too clinical and detached, making it difficult for people to engage or to open up about their mental health concerns. Research suggests that some groups (including black men) may benefit more from appointments in non-clinical settings, such as community spaces, groups and churches[13]
. Mental health services must be designed and commissioned with input from those who are currently not being catered for.

Improving choice

We need national commitments to improving mental health services on the ground. But this isn’t just the responsibility of GPs or the IAPT programme. For change to happen, we need a cross-governmental strategy that addresses poor housing, employment issues and benefits, which all have a huge impact on our mental health.

There’s no ‘silver bullet’ for this problem, but we will continue to hold the NHS and government to account and push for real and lasting change, so everyone with a mental health condition gets the support they need.

Geoff Heyes, head of health policy and influencing, Mind

References

[1] NHS Digital. 2019. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/prescription-cost-analysis/2018 (accessed February 2020)

[2] Royal College of Psychiatrists. 2020. Available at: https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/antidepressants (accessed February 2020)

[3] Joint Formulary Committee. 2017. Available at: https://bnf.nice.org.uk/treatment-summary/antidepressant-drugs.html (accessed February 2020)

[4] Ijaz S, Davies P, Williams CJ et al. Cochrane Database Syst Rev 2018;5:CD010558. doi: 10.1002/14651858.CD010558.pub2

[5] Robinson J. Pharm J 2019;303(7930). doi: 10.1211/PJ.2019.20207226

[6] Price C. 2014. Available at: http://www.pulsetoday.co.uk/clinical/clinical-specialties/mental-health/gps-forced-to-prescribe-as-psychological-therapies-services-are-bursting-at-seams/20007033.article (accessed February 2020)

[7] NHS Digital. 2019. Available at: https://digital.nhs.uk/news-and-events/latest-news/iapt-2018-19 (accessed February 2020)

[8] Mind. 2013. Available at: https://www.mind.org.uk/media/494424/we-still-need-to-talk_report.pdf (accessed February 2020)

[9] British Medical Association. 2018. Available at: https://www.bma.org.uk/news/media-centre/press-releases/2018/february/new-bma-research-unveils-blindspot-in-mental-healthcare (accessed February 2020)

[10] British Medical Association. 2018. Available at: https://www.bma.org.uk/connecting-doctors/b/work/posts/iapt-is-great-but-what-about-our-other-patients (accessed February 2020)

[11] BMJ. 2019. Available at: https://blogs.bmj.com/bmj/2019/10/21/improving-access-to-psychological-therapies-an-idea-thats-failed-to-deliver (accessed February 2020)

[12] Mental Health Foundation. 2006. Available at: https://www.centreformentalhealth.org.uk/publications/we-need-to-talk (accessed February 2020)

[13] Mantovani N, Pizzolati M, Edge D. Health Expect 2017;20(3):373–384. doi: 10.1111/hex.12464

Last updated
Citation
The Pharmaceutical Journal, PJ, February 2020, Vol 304, No 7934;304(7934):DOI:10.1211/PJ.2020.20207719