Doctor's little helpers

The prescribing of antidepressants has soared in recent years even though some patients feel they are not a suitable treatment for them. But can GPs under pressure be blamed for dishing them out?

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After the birth of her first child, Carla Lett started to feel down. During her pregnancy she suffered from placenta previa, and was plagued with the knowledge that her unborn baby could arrive at any time. When her son was born at 33 weeks gestation in April 2016, Lett was unable to hold him without permission from staff on the maternity ward and says she struggled to bond with her baby as a result.

“I was detached really,” she says. “It was really hard. It’s totally different now but when I walked down to see him someone else was changing his nappy. I think I just felt like he wasn’t mine.”

Six months later, Lett’s feelings about motherhood had not improved so she went to her GP. “I felt these symptoms but I didn’t admit it to myself,” she says. “I felt really low and I didn’t want to see anyone at all, which is unusual for me because I am a very sociable person.”

During the appointment in October 2016, Lett told her doctor she was struggling to sleep at night and was finding it difficult to bond with her son. She was just hoping for some reassurance that how she felt was not uncommon in new mothers, so she was surprised when she was given a three month prescription for citalopram, an antidepressant known as an SSRI (selective serotonin reuptake inhibitor).

“There was no real discussion. I was in there for about five minutes and I was clearly upset. He didn’t really take any time to find out what was wrong. He just said ‘I think you’ve got a case of anxiety’ and advised me to take the pills to calm me down. I was surprised. I felt a bit sad because I just wanted to talk to someone about it.”

“It was like someone else was living my life, like someone else was in my body. I didn’t feel bothered about anything.”

SSRIs are the most widely prescribed type of antidepressants. It’s thought that they work by increasing serotonin levels in the brain. After carrying a message, serotonin is usually reabsorbed by the nerve cells (known as “reuptake”). SSRIs work by blocking (“inhibiting”) reuptake, meaning more serotonin is available to pass further messages between nearby nerve cells. It is believed serotonin helps regulate everything from sleep to appetite to mood. According to the NHS website SSRIs are usually preferred over other antidepressants as they cause fewer side-effects, but for Lett she started feeling the effects straight away.

“I felt numb. I felt like I was a zombie,” she says. “It was like someone else was living my life, like someone else was in my body. I didn’t feel bothered about anything. It sounds awful because I love my husband to bits but at that time I think if he’d left me for another woman I just would have been like: ‘Right, OK.’ I didn’t feel better. I didn’t have the anxiety anymore but it just numbed everything.”

Lett decided to stop taking the pills four months later. She describes a breakthrough moment when she cried while watching Jeremy Kyle.

“I remember thinking to myself this is the first time I’ve cried in ages and I was so happy that I cried because I didn’t think I was bothered about anything when I was on them,” she says.

Lett’s son is now approaching his second birthday. Although she does feel down at times she has found a way to make herself feel better without the need for medication.
“Exercise for me is brilliant. Sometimes I don’t want to go but I make myself go about four times a week and I come back like a new person.”

A report by NHS Digital in June last year showed antidepressant prescriptions more than doubled from 2006 to 2016 and in 2016 had the biggest increase in prescribing of any drug, with 64.7 million items dispensed – 3.7 million more than in 2015 and an all-time high.

The report prompted a debate about whether antidepressants are being prescribed too freely and whether GPs should be offering alternative therapies such as counselling before medication.

Looking back, Lett feels her GP should have explored other options before antidepressants.

“He should have offered some sort of therapy or counselling. I don’t want to speak badly about my GP because I know how much pressure they are under and I know he thought he was doing the right thing, but I just felt that for me antidepressants weren’t the answer.”

Mental health provision, or the lack of it, continues to be a major talking point for charities, doctors and politicians. According to the British Medical Association, spending on mental healthcare is just 11 per cent of the current NHS budget, despite accounting for 23 per cent of the burden of disease in the UK. A survey of NHS trusts last year also suggested that mental health services in England risk being overwhelmed by rising demand and staff shortages. The question is, are GPs prescribing antidepressants because there is a shortage of other options?

Hanna Cevik has been prescribed antidepressants on three occasions when she has felt she hasn’t needed them. On one occasion she went to a locum GP with symptoms of irritable bowel syndrome, and says she felt that the doctor was trying to push a depression diagnosis onto her.

“He just kept saying to me: ‘Do you think this is because you are depressed?’ I said: ‘Do you think the reason that I can’t digest my food is because I’m depressed?’ I felt like he’d decided that that was what I was really reporting. He couldn’t get beyond that. I was asking him about going to see a nutritionist or a specialist, and he just said: ‘Let’s eliminate the depression possibility first’.”

Cevik: asked for counselling, defaulted to drugs

On another occasion, Cevik went to her GP to ask about accessing counselling services as her sister was ill in hospital and she wanted someone to talk to, but the GP immediately suggested antidepressants.

“My sister was very ill. It was incredibly stressful and pulling the family in directions that nobody wanted to explore,” says Cevik. “I went to the GP and said we are physically in different locations so we can’t have something like family counselling where we sit there with a person who can mediate for us. I said I am really struggling, I need a place where I can go and talk to somebody about how I can park these feelings and all of this thinking I’m having to do about my sister and my family. And again, it was a really similar situation – they said they could give me antidepressants.

“In this situation I could understand why that would be a potential answer but I went to ask for counselling and they defaulted to giving me drugs. I just worry about the people who say yes to that and then find themselves stuck in a cycle where they haven’t been helped – they have just been drugged.”

Last month a major study of antidepressants by Oxford University concluded that they do work. The study, which analysed data from 522 trials involving 116,477 people, found 21 common antidepressants were all more effective at reducing symptoms of acute depression than dummy pills. The Royal College of Psychiatrists said the study “finally puts to bed the controversy on antidepressants”, but David Healy, a psychiatrist, psychopharmacologist and professor in psychology at Bangor University, says the results are not that straightforward.

“What they mean is that they have an effect,” says Healy. “These are very short trials. In the same kind of trialand the same kind of approach, I could show you that alcohol works. On the basis of these short term trials, GPs are handing out drugs that we know less about than alcohol. If it was a drug like alcohol, which they knew what the risks are, do we really want to give this teenage girl alcohol just to calm her down and help her over the next few weeks?

“They would be a lot slower to do it than they are with SSRIs. They are handing out SSRIs thinking that they are much safer than alcohol, when in fact they are probably much riskier.”

In 2015 researchers writing in the British Medical Journal criticised GlaxoSmithKline for delaying access to key data from a trial of its antidepressant Seroxat that would have shown earlier that it was neither safe nor effective in adolescents. It is the lack of access to information from drug companies that Healy says is a big problem.

“The Oxford study mentions clinical trials,” says Healy. “These are company trials and nobody has access to the data. The Oxford guys who wrote the paper didn’t have access to the data, the people who ran the trials didn’t have access to the data. The companies hold the data, so the data will often indicate what the risks are of the treatment, but nobody gets to see that. The regulators don’t get to see it, clinicians don’t get to see it, so from my point of view these are not clinical trials. If it’s a clinical trial it is a thing that’s done in the public domain and there’s access to the data afterwards. There is essentially not a single clinical trial on antidepressants which meets that criteria.

“I’m not saying that the effect of these drugs are all in the mind. Absolutely these drugs do things but I don’t need a clinical trial to tell me that. I can just give them to you and you will be able to tell me within a day or two that those drugs do things to you. The question is, are we putting them to good use? And I would say we are not.”

Hannah Brown was offered citalopram when she went to her GP concerned she was developing an eating disorder.

Brown says: “I was told that I didn’t have an eating disorder or any problems with food. The default position was: ‘She must be depressed – let’s give her antidepressants.’ Actually I didn’t have any symptoms or signs of depression.”

Brown is now in recovery and campaigns about mental health and eating disorder awareness. She believes GPs should have more support in order to treat patients properly.

Brown: no signs of depression

“The biggest problem is that GPs have seven minutes during an appointment to listen to you, make a diagnosis and prescribe,” says Brown. “That is ridiculous – they can’t do their job. They want to make sure that the person sitting in front of them is safe, and if the only thing they have got in their resource is this prescription then they have to do it. They need to know that within that seven minutes they tried to help you. You can’t put the blame on the GP. You have to look at everything that is going on around it.”

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, tells Big Issue North that the decision to prescribe antidepressants is never taken lightly by doctors, but she acknowledged the need for better access to other psychological therapies, such as cognitive behavioural therapy and counselling. Stokes-Lampard says: “GPs are highly trained to help patients with mental illness, including depression and anxiety, and understand the potentially devastating effects the condition can have on their lives if not treated and managed properly.

She said recent research has confirmed that antidepressants are an effective treatment for some patients but not others, and said GPs will prescribe them if they think it’s the best course of action for the person sitting in front of them.

“However, we cannot be sure in advance which patients will benefit most from a course of the medication.

“GPs will only recommend a course of drugs after a full and frank discussion with the patient, outlining the potential health benefits and risks, and having considered the social, physical, and psychological factors potentially impacting on their health.

“GPs will also aim to manage antidepressant use in patients carefully, and conduct regular medication reviews to minimise complications. We also know that depression is best treated alongside other psychological therapies, such as cognitive behavioural therapy or talking therapies, so will always explore these options.

“Unfortunately, these services can be hard to come by at community level, and we need better, quicker access to them if we’re to deliver the care we want to.

“NHS England’s GP Forward View has pledged that every GP practice in England will have access to one of 3,000 new mental health therapists. We need this, and its other promises, including an extra £2.4 billion a year for general practice and 5,000 more GPs, to be delivered in full as a matter of urgency, so that we can continue to provide the mental health care patients need and deserve. n

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Interact: Responses to Doctor’s little helpers

  • Fiona French
    06 Apr 2018 11:18
    Further to my earlier comment, Dr Neil McFarlane, MPsych has submitted a formal complaint to the General Medical Council with respect to the behaviour of Prof Carmine Pariante MRCPsych, Spokesperson, Prof Wendy Burn FRCPsych, President and Prof David Baldwin FRCPsych, Chair of Psychopharmacology Committee.
  • Alyne Duthie
    06 Apr 2018 01:19
    I very much regret my 30 plus years on one kind of antidepressant or another. The majority of my adult life has been spent being chronically unwell due to side-effects. I gained weight, suffered urinary and bowel problems, experienced heavy sweating, blunted emotions, chronic fatigue, blurred vision, and much else besides. These are drugs that we are told will allow us to function and cope with everyday life and yet this not how things panned out for me. With every passing year my health deteriorated to the point I struggled to get out of bed. It took me a long time to appreciate that this had everything to do with the antidepressant I was taking and very little to do with me. Of course no one within the medical world actually spells out how incredibly hard it can be to get off the drugs and the tapering advice doesn't adequately reflect that patients like myself are long-term consumers of SSRIs/SNRIs. Withdrawal from Effexor in early 2011 was so brutal that I was driven to attempt suicide a year and a half later. The Royal College of Psychiatrists of course would have you believe that withdrawal is mild and transient. From the people I talk to in the prescribed harm community, this beggars belief. I naively thought that patients whose lives have been negatively impacted by prescribed psychotropic drugs would get a hearing from their prescribers, how very disheartening it was to realise that this is far from the case. Doctors and psychiatrists will continue to harm patients if they remain divorced from the negative realities of their neurotoxic medications. I'm still suffering from being prescribed antidepressants and from the cocktail of other drugs, like diazepam, I was desperate enough to consider in the worst of years of my withdrawal. If I'd really had the benefit of informed consent I feel my life would have been very different but as it is I'm anxious about the long-term consequences of trusting the advice of my doctors.
  • Stuart Simpson
    05 Apr 2018 01:46
    I would like to say that in my own case which was 225mg of venlafaxine for work related stress. I was unaware at the time that 225mg of venlafaxine is not what would be termed 'standard procedure' for 'work related stress' I was questioning why a GP was so keen on using anti depressants for myself hating my job whilst I was actively and did succeed in gaining alternative employment. The GP got myself to agree to sign up to a programme from venlafaxine's then manufacturers, Wyeth, whereby a nurse would phone me every so often to give me a little pep talk. Although I did suspect that the GP had a less than honourable motive, being a naïve and trusting member of the public(I have no trust in doctors now, not one shred or ounce of it) I failed to make the connection that this meant that GP had been having dealings with sales reps from Wyeth. Had I realised this I would have held the prescription up in front of the GP and said, 'I know what your at, your chasing incentives from pharma reps' and ripped the prescription up in front of him. I should also point out given the cost of venlafaxine compared with other anti depressants that the GPs prescribing decision was not about saving the NHS money, but then why he should he care about how much it was costing the NHS to ruin my life as its isn't the GP who pays for the drug is it? I was also unaware at the time that venlafaxine in this country is normally only prescribed in the first instance by psychiatrists and is not something that a newly qualified GP would normally be using in their practice. This also begs another question, 'What was a medical rep from Wyeth doing anywhere near a newly qualified GP given that GP's do not normally use this drug in their practice. Wherever one gets human beings one also gets corruption. Apparently, 2000yrs ago there was in Palestine a Lake Gallilee Fisherman who was incorruptable-he got nailed to a cross by the rest of us. Scholars of Prohibition in America reckon that perhaps as much as 80% of 'medicinal alcohol' was ending up in the hands of the likes of Al Capone-Doctors had unlimited access to alcohol for medical purposes and it had been overlooked that being human and therefore corruptible that the doctors might just sell the medicinal alcohol on to the local bootlegger. I dealt with the work stress problem by getting a new job which I then lost after 8 months as venlafaxine had turned nasty on myself and GP was refusing to admit that what he was prescribing was incapacitating myself. I had to cold turkey off 225mg of venlafaxine due to this and have never been right since, that was a decade ago. When I sought GPs help for stress issues I hadn't had a day off sick for 20 months and had not in fact been to a Doctor for 4 yrs. I quickly found myself unemployable. And it was all paid for by the taxpayer, not the GP and the taxpayer is still paying for what the GP did. It's quite obvious to myself that doctors do not pay to tidy up the mess that they create, you do, yes you who is reading this, it's you that's been paying to tidy up the mess via the taxes that you pay for the NHS and the Benefits system(which I've just re-joined due to a flare up in my symptoms again). I'll leave it at that for the moment as there is quite a few chapters more to my own story
  • Samantha Long
    04 Apr 2018 19:31
    Readers should also be aware that there are other options to access counselling and therapy other than the nhs. Local counselling charities can offer support for free or a small contribution.
  • Fiona French
    04 Apr 2018 14:07
    Thank you to the Big Issue for publishing this article. Antidepressants of course carry with them the risks of dependence and withdrawal symptoms can be long-lasting and severe. GPs may have expertise in dealing with depression and anxiety but they do not seem to be aware of the damaging effects of the drugs themselves, nor do they recognise and understand the dreadful symptoms that are associated with withdrawal. Following the widespread orchestrated media coverage of the Cipriani paper in the Lancet, Profs Wendy Burn and David Baldwin of Royal College of Psychiatrist published a letter in the Times newspaper stating that the withdrawal symptoms only last for two weeks for the majority of patients. A formal complaint has now been made to RCPsych by 30 academics, clinicians and patients seeking retraction of this letter in the interests of patient safety. It is astonishing that this claim should have been made not long after Public Health England announced a year long review of prescribed drug dependence and a six year research project is currently underway at Southampton University into antidepressant withdrawal. The Royal College of Psychiatrists is very keen to promote more prescribing of antidepressants but the evidence base for their effectiveness is very modest and of course as Prof Healy points out, no one has been allowed access to original clinical trial data. Many patients experience suicidal feelings and thoughts either when taking or withdrawing from these drugs and a proportion have of course taken their own lives. GPs are clearly under pressure and lack enough time with their patients but at the same time a great deal of iatrogenic harm is resulting from these drugs, creating more pressure on GP appointment time, as patients seek help for the resulting damage, some of which may well be long-lasting and even irreversible. If patients are prescribed these drugs without being informed of the risks then there is no informed consent to treatment. Patients in the prescribed dependent and harmed community have been left with no choice other than to campaign for appropriate dedicated withdrawal services and a reduction in antidepressant prescribing rates. They have liaised with the BMA and All Party Parliamentary Group on Prescribed Drug Dependence and have raised petitions at the Scottish Parliament and Welsh Assembly. Perhaps the Big Issue could publish a further article on this subject encompassing these issues and featuring some of the patients whose lives have been blighted or even destroyed by antidepressants. It is astonishing given all that is happening that RCPsych is promoting increased prescribing rates and that GPs should be criticised for being "squeamish" about prescribing for mental health issues - see Prof John Geddes, University of Oxford, quoted in Times newspaper, 22 February. There is something very far wrong, very far wrong indeed.

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