GPs must stop putting people into diagnostic boxes and pause before prescribing antidepressants

UCC hosts a major mental health conference tomorrow and Thursday and in advance of the conference Bryan McElroy, an Irish GP working in the NHS, says Ireland needs to examine its approach to antidepressants.

File and unrelated image of GP speaking to patient
File and unrelated image of GP speaking to patient

Prescriptions for antidepressant drugs have increased substantially worldwide in recent years. A study examining prescribing trends for mental disorders in England from 1998 to 2010 found that antidepressant prescriptions increased by 10% per year on average.

In Ireland, between 2009 and 2017, prescriptions for eight antidepressants available from the Health Service Executive (HSE) increased by 64%. GPs are typically the first professional a person consults when they experience symptoms of depression for the first time, so I felt I had to examine the increased trend in prescriptions.

In everyday practice, a structured approach is necessary to ensure that GPs are prescribing safely and effectively, in accordance with current, evidence based best practice, and to ensure that patients are told about the pros and cons of starting antidepressant therapy. Indeed, clinicians have an ethical duty to educate patients, so they are able to make a fully informed choice about this important therapeutic intervention.

However, in clinical practice, I have encountered many cases where patients have been started on antidepressant medications without being given any such information.

In a recent survey people taking antidepressants, 55% of those who attempted to stop their medication experienced withdrawal effects, and 27% became addicted to the medication. Only one per cent of participants recalled being told about withdrawal effects when prescribed the drugs

Further complexities arise when you consider the uncertainty surrounding how antidepressant therapy actually produces beneficial effects. Meta-analyses of published and unpublished data show no statistically significant difference for the most commonly prescribed type of antidepressant, selective serotonin re-uptake inhibitors (SSRIs), over placebo for mild to moderate depression, and only slight differences for severe depression.

This suggests that a large proportion of antidepressants’ mechanism of action is due to the placebo effect rather than the correction of a specific ‘chemical imbalance’, as was initially hypothesised. There is now significant evidence to show that adverse childhood events (ACEs) are associated with depression in later life, raising the possibility that the root of some cases of depression may be unresolved psychological trauma.

A study of 2,047 men and women conducted in Mitchelstown, County Cork, found that ACEs are common among older adults in Ireland and are associated with higher odds of later-life depressive symptoms, particularly among those with poor perceived social support.

Inaccurate, or at least unproven, scientific assumptions have become the basis for much of what GPs currently communicate to patients and how we practise.

When it comes to antidepressant prescribing, there seems to be an ingrained habit not to fully inform patients by not explaining honestly and comprehensively about the nature of depression and the pros and cons of drug therapy. This is clearly an area that needs more attention in primary care.

GPs must stop putting people into diagnostic boxes and pause before prescribing antidepressants

Obstacles to change

I have encountered many factors in general practice that contribute to poor-quality antidepressant prescribing.

Views on what causes depression, what antidepressants are, how they work and how safe they are vary widely within the medical community. In my experience, the information doctors have about antidepressant medications largely depends on their education and training in medicine and psychiatry, the books or journals they read and the frequency of contact they have with pharmaceutical representatives and advertisements.

Most Irish GPs (I would estimate 90%) meet pharmaceutical company representatives and advertising on a very regular basis. Pharmaceutical company information tends to downplay risks and exaggerate the beneficial effects of antidepressant drugs, giving the drugs a positive appeal to GPs.

It is also clear that exposure to pharmaceutical advertising affects GPs prescribing decisions(7). Perhaps more importantly, the theory that a ‘chemical imbalance’ is the root cause of depression still predominates in medical culture, and if GPs believe this theory (which, in my opinion, most GPs do), this influences their prescribing habits and the information patients receive from them.

GPs often perceive there are few options other than prescribing medication when someone presents with depression. There is a sense of obligation to do something meaningful to help the person who is in obvious distress and GPs may have little or no education, experience or interest in alternative options for guiding someone out of a depressive episode.

Mental health issues typically require longer and are more complex consultations than, say, a sore throat. As taking a thorough history and engaging in active listening takes up most of the time of these consultations, fully informing patients about antidepressant therapy creates a time management challenge.

With 10-15 minutes for consultations being standard in most GP practices in Ireland, fully informing patients about antidepressant drug therapy is often put on the back burner and eventually forgotten about. Patients often have pre-existing beliefs either for or against antidepressant medication. Exploring these beliefs and coming to a consensus decision poses yet another time pressure and clinical challenge.

Coming to a consensus on whether to prescribe and how to prescribe an antidepressant and then how to describe antidepressant drug effects is quite a complex issue.

GPs must stop putting people into diagnostic boxes and pause before prescribing antidepressants

How to bring about change?

I do not believe GPs intentionally mislead patients; they aim to guide patients toward what is best for their physical, emotional and psychological wellbeing. However, GPs act on what they know, or think they know, and are trained to diagnose and treat based on a predominantly biomedical model of responding to human beings presenting in distress.

The fact that GPs are the first port of call for people in distress is something, I think we as a society, need to question (Commas added to this sentence). Why do we encourage people in very low mood and typically with complicated mental and emotional struggles to seek help from a professional who has 10 to 15 minutes to try to alleviate their distress?

GPs are encouraged and trained as doctors to give proactive medical responses to states of distress within this 10–15-minute consultation framework.

They do this by putting people into diagnostic boxes. Each of these diagnostic boxes (for example, depression) is associated with specific drugs that the doctor will immediately call to mind – and in the case of depression, these will be antidepressants.

Many GPs I speak with are frustrated because they understand the limitations of psychopharmacology, they recognise the need for a range of responses to human distress and they are mindful of the social and personal determinants of mental health – they deal daily with ordinary people trying their best to manage the ups and downs of life. This whole system needs rethinking and remodelling in order to avoid more more people being inappropriately prescribed antidepressant medications for lack of alternatives – drugs that may be doing them more harm than good.

What GPs can do is communicate the facts about what we know about depression and antidepressant therapy.

We can have open, clear, transparent discussions with patients about the potential benefits, risks and limitations of the psychotropic drugs we prescribe. But one of my main concerns is that many GPs are themselves not fully aware of the facts when it comes to depression.

Many have never questioned the theory they were taught in medical school – one that is re-iterated by pharmaceutical marketing – that depression is due to a biochemical imbalance in the brain. In my view these are the areas that most need to change in general practice, in medical schools and even in psychiatry.

In order for GPs to change how they practise, they need to be educated in a more thorough, holistic and realistic way about the pros and cons of the psychotropic drugs they prescribe. And for this to happen, we need to be relieved of the pharmaceutical influence that prevails in Western medical education settings.

This is an edited extract from the book - INSIDE OUT OUTSIDE IN TRANSFORMING MENTAL HEALTH PRACTICE – which will be launched in UCC at a major mental health conference on 13&14th November - ‘CHALLENGING MENTAL HEALTH SYSTEMS: CRITICAL PERSPECTIVES FROM INSIDE OUT AND OUTSIDE IN’ - explores perspectives from both within and outside mental health systems, considers the struggles, challenges and barriers people have experienced at developing new approaches.

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