OPINION: Antidepressant use polarising doctors

THE British Medical Journal has just published two opposing views on the question of whether antidepressants are being over-prescribed.

The issues raised by debate are  not unique to the United Kingdom; increasing rates of antidepressant prescribing are apparent in most developed countries, including Australia.

The journal’s discussion was precipitated by recent UK  data which reported a 9.6per cent increase in antidepressant prescriptions in 2011 – the largest increase in prescriptions of all medication classes for that year.

Arguing that the figures indicated over-prescribing, general practitioner Des Spence writes, “I think that we use antidepressants too easily, for too long, and that they are effective for few people [if at all]’’.

In the opposing camp, professor of psychiatry Ian Reid contends: “Given recent demonstrations that depression is still under-recognised and under-treated, the claim that antidepressants are over-prescribed needs careful consideration.’’

In Australia, a recent report on prescribing patterns of antidepressants and other psychotropic medications (drugs for mental illnesses) has aroused similar controversy . 

The study’s authors reported a 58.2per cent increase in the dispensing of psychotropic drugs over the period from 2000 to 2011, including a 95.3per cent increase in antidepressants.

Echoing the argument that antidepressants are being over-prescribed, the authors raised concern about “the dramatic increase in antidepressant prescriptions despite questions about the efficacy of these drugs in mild to moderate depression’’.

These recent UK and Australian data are not surprising; they are consistent with the major increase in antidepressant prescribing that’s been occurring in most developed countries since the introduction of the SSRI (selective serotonin reuptake inhibitor) antidepressants in the late 1980s and early 1990s.

In terms of adequacy of depression treatment, a 2007 national survey found that 6.2per cent of individuals had experienced a mood disorder (mainly depression) over the prior 12 months, but over half (51.2per cent) did not access any services for mental health problems in that time. This indicates a substantial unmet treatment need for depression, rather than over-treatment.

While it’s not possible to identify rates of antidepressant prescribing, as such, from the survey, the rate of use for psychological services was 23.2per cent for those with a mood disorder. 

This is a substantial increase from the 11.8per cent in an analogous 1997 survey, suggesting that doctors were readily utilising psychological services via Commonwealth-funded schemes such as Better Access.

Overall, these data do not indicate that there’s over-prescribing of antidepressants in Australia.

A second potential measure of the value or otherwise of this increase in antidepressant use is its impact on suicide rates.

We examined this question in 2003, and found there was a significant correlation between changes in antidepressant prescribing rates from 1991 to 2000 and the rates of suicide. 

We also found that people in age and gender groups with increased rates of prescribing were demonstrating lower suicide rates.

We interpreted our findings broadly – that effective treatment of depression, whether by medication or psychological treatment can lead to a measurable benefit (here a fall in suicide rates), even at a whole population level.

While rates of prescribing are undoubtedly increasing, data from national surveys suggest continuing high rates of untreated depression as well as increased use of psychological services. 

And, as discussed above, findings from a number of developed countries, including Australia, indicate the public health benefit of reduced suicide rates.

Still, we must remain vigilant in monitoring such prescribing, particularly for milder depression where psychological treatments are probably more appropriate.

Phillip Mitchell is the head of the School of Psychiatry at the University of NSW. This article was originally published at theconversation.edu.au

If you think you may be experiencing depression or another mental health problem, please contact your general practitioner or phone Lifeline on 131114.

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