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Chief Executive

Antidepressants – the start, not the end, of the conversation

07 June 2019 | by Chief Executive

The following article has been published on behalf of our CEO in response to the recent position statement issued by the Royal College of Psychiatrists.

Last week the Royal College of Psychiatrists issued a new position statement on antidepressants and depression.

The statement primarily recognised the potentially negative and, in some cases, long-lasting symptoms associated with antidepressant withdrawal, as well as the potential risks of overprescribing, and will likely be well received by many of the service users and groups calling for greater recognition and acceptance of this issue.

There were also a series of recommendations aimed at improving support and guidance for clinicians, which the Society has welcomed, including calls for the commissioning of support services for those most affected by antidepressant withdrawal and greater research into the potential harms of long-term antidepressant use.

This position statement is particularly timely given that NICE is currently working to update its guidance on depression, which was last issued in 2009.

The total number of prescriptions issued for antidepressants across the UK in 2017 stood at over 82 million, a figure that has almost doubled in the last decade.

And yet, despite this substantial increase, it hasn’t been mirrored by a similar rise in the prevalence rate of depression within any region of the UK over the same period.

What we see instead is a worrying trend of a significant minority of people with depression not accessing the support they may need.

In fact, figures from NHS Digital suggest that a third of adults with depression in England at a level requiring intervention do not receive any treatment.

This statistic paints a worrying picture where antidepressant prescriptions have grown considerably, even as overall rates of depression have increased only slightly, while, at the same time, there are also millions of people across the UK still not receiving adequate support. 

Any intervention for depression should be based on sound psychological-evidence and be entered into freely with informed choice based on any potential benefits and risks. Wide inequalities in access to psychological treatment, however, mean this is not a reality for many people across the UK, and research has found that for some psychological treatments waiting times can be as long as two years.

Even within the Improving Access to Psychological Therapies (IAPT) programme waiting periods range from a speedy five days in Stoke-on-Trent to a much slower 135 days in Leicester.

Psychological treatment may not even be a viable option available to many, if those services are not designed to accommodate their personal circumstances or backgrounds. Though the College’s statement recognises that LGBT people and people with intellectual disabilities may not be well served by existing services, it fails to mention that this is also the case for BME people who also report poorer treatment outcomes.

People from BME communities are more likely to perceive greater barriers to accessing services, and may encounter psychological treatments that do not fully consider the lived experience of social injustice and hierarchies that can contribute to depression in the first place.  

It has been suggested by some that the lack of accessibility is driving this marked rise in antidepressants prescriptions, with antidepressants being seen as the only option available in the face of long wait times and unsuitable services.

However, inclusively designed and easily accessible psychological therapies can play a role at any stage of intervention, be it following a course of antidepressants that have enabled someone to engage with them, or to support with withdrawal given the now recognised potential for harmful symptoms.

As such, new guidance on antidepressant use will be of most use when it is combined with a similar freedom of information, choice and access to psychological therapies. 

It is vital that we don’t just see intervention as being necessary only when people are already experiencing moderate to severe depression. The College highlights that unemployment rates may influence variation in prescribing rates across England, but this is just one of the myriad social factors that can contribute to depression and in turn the need for intervention.

Prevalence rates of depression are markedly higher in low-income regions and areas where communities experience multiple deprivation, and it has been shown that income inequalities can work to erode social cohesion across communities, leading to social isolation and alienation.

The position statement on antidepressants and depression has been welcomed by many across the board. It updates its position based on new evidence and makes recommendations for further high quality research and guidance for clinicians.

Like all statements however, it should be the start and not the end of the conversation, as there is much more that can be done to improve access to psychological therapies, from considering new ways of delivering services to community based approaches that recognise and address social injustices that may be at the root of any need for intervention.

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