SPECIAL REPORT: A state of high anxiety over Ireland's antidepressant prescription

Today's Irish Examiner investigation should be the beginning of a wider-ranging look at the manifold variations of antidepressant prescription around the country, says Siobhán Barry.

With the move from the fragmented Health Board system of care to a streamlined HSE in 2005 it was expected that 'post code' differences of practice might be ironed out and that should disparities become apparent, these would be examined to account for discrepancy and appropriate remedial action to follow.

Today's piece by Catherine Shanahan reveals wide national variations in prescribing psychotropic medication that might reasonably have been expected to have been recognised and analysed internally by the HSE in their routine audits of their financial outlay and explanations sought.

Data presented here referred only to those who either sought some form of reimbursement of the cost of their medication from the state, comprising over 71% of the population in the year studied.

Therefore the findings are indicative and a more indepth analysis of this material should be carried out by health economists.

Other than a scholarly paper on differences in prescribing practices in Ireland by Martin Kenneally and Brenda Lynch of the Centre for Policy Studies in UCC there appears to be little research interest in prescribing variations in Ireland.

The information available shows inconsistency in the prescription of antidepressants and antianxiety medications from local health office to local health office.

Not alone are there differences in the rates of prescription per head of population but also there are many-fold variations in the quantities of individual medication prescribed from area to area.

Anxiety is an unpleasant state of inner turmoil with accompanying unpleasant feelings of dread over anticipated events. It is often accompanied by muscular tension, restlessness, fatigue and problems in concentration.

Anxiety treatment recommendations include making lifestyle changes, anxiety management therapy to enable better symptom management, and medications.

Medications are typically recommended only if other measures are not effective and it is universally recommended that such medication is prescribed for a short period of time due to the risk of dependency.

Typically, an anxious air traveller might take an antianxiety pill such a diazepam or alprazolam [xanax] to help them get on a plane, stopping such medication once they land.

Such anti anxiety medication work quickly but they can lead to dependency when they continue to be prescribed.

Depression tends to comprise a complex set of mental and physical symptoms and the response to medication tends to take some time to come to effect.

In addition such medication needs to be reviewed at regular intervals and medication often tapered down slowly after 6 months of recovery.

Large scale comparisons show that licenced antidepressants are similarly effective in treating major depressive disorder in adults and any differences in efficacy are small and unlikely to be clinically relevant.

Why then are medications that span a range of cost but without a corresponding range of efficacy, prescribed without much attention to their cost?

Of course, in a number of cases, there can be individual differences in how well medications are tolerated accounting for some variation in prescribing.

Distress tolerance skills help us survive short term or longer term physical or emotional pain arising in situations that we cannot change. These skills can be taught and are extremely practical.

As the name suggests, the acquisition of such skills which include acceptance of the suffering, distraction, physical activity, self-soothing and social pursuits help better manage worry in place of or complementary to the taking of medication.

Mastering and applying such skills are treatment options that should be central to treating anxiety and depression.

In 2006, the Irish College of General Practitioners set out Guidelines for Management of Depression and Anxiety in Primary Care.

Those Guidelines provided 'recommendations based on current evidence for best practice in the management of depression and anxiety disorders including screening, assessment, diagnosis and management, providing step by step algorithms for the management of depression and anxiety disorders'.

In addition those treatment guidelines specify that psychological treatments need to be available to supplement or replace pharmacological treatment.

Such processes and procedures should lead to greater uniformity of practice - so why the inconsistencies of prescribing?

In late 2002, Good Practice Guidelines for the prescribing of Benzodiazepines were published by the Department of Health & Children highlighting that benzodiazepines may be prescribed safely in the short-term treatment of anxiety and are only indicated when the disorder is severe, disabling or subjecting the individual to extreme distress.

Emphasis was put on the danger of dependence, then recognised as a significant risk in those receiving treatment for longer than one month and prescribers were advised to be conscious of this when evaluating the relative benefits and risks of continued prescription.

In addition to the dependency risk, such medications may be sedating especially in the elderly and increase the risk of falls.

Forming new memories and learning new material, such as would be expected in engaging in a psychological programme can be adversely affected by these medications.

So, why is it that some areas appear to prescribe diazepam [valium®; Roche] and alprazolam [xanax®] by a factor that is a multiple of other areas?

Are those areas more prone to depression and anxiety or the treatment available in those areas limited to pharmacological intervention only?

Today's article opens up a topic that must interest those prescribed such medications and their families.

It must also raise the curiosity of the taxpayer and the prescriber.

Could it now also become a matter of enquiry for the health and pharmacoeconomists among us?

SPECIAL REPORT: Our €40m drug problem

SPECIAL REPORT: The anti-depressant generation


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