January 18th, 2018, Maureen Watt MSP, Minister for Mental Health, attended a Public Petitions Committee meeting at the Scottish Parliament. This was the second hearing of the Petition “Prescribed Drug Dependence and Withdrawal”, which specifically relates to antidepressants, benzodiazepines and other drugs used in Mental Health. Would I finally have the answers to why in their 2017-2027 Mental Health Strategy, the Scottish Government had failed to address the issue of soaring antidepressant prescribing in Scotland? This issue is becoming an ever-increasing problem individually, socially and economically in Scotland.
According to Maureen Watt, Minister for Mental Health, there appears to be no problem at all! She stated the government’s work in reducing stigma has meant more people have been coming forward to seek help from their GPs for problems such as depression and as a consequence more people have been prescribed antidepressants.
The Minister for Mental Health claims, “The quality of antidepressant prescribing has improved in recent years. Too often a less than effective dose was prescribed for too short a period of time, now higher average doses are prescribed for longer, more appropriate periods. That is a more effective approach, which reduces the risk of recurrent bouts of illness in the long term.”
So from HEAT targets to reduce antidepressant prescribing in 2010, how did we arrive at a Government in 2018 who claim prescribing at higher average doses for longer periods of time is better for patients? As I listened closely to our Minister for Mental Health being questioned, I found what I was hearing incredible and far from ‘Realistic’.
“There is consistent evidence of undertreatment of depression and we know that the personal and economic costs of having it are high. The evidence for antidepressant treatment reducing relapse is strong. There is no evidence that having greater access to psychological therapies will reduce antidepressant prescribing,” said the Minister
Maureen Watt said "the Scottish Government will continue to emphasise the importance of parity in physical and mental health services and that people should receive medication if they need it, 'just as someone should receive medication for a physical illness'. Medical student teaching now emphasises medication has an important place in treatment. It should not be overused or continued indefinitely, taking place within an enabling environment, in which support and a range of information sources are readily accessible to patients"
In 2015/16 Scotland spent £44 million on antidepressants. With one in three GP appointments now having a mental health element GPs continue to bear the burden of Scotland’s reliance on antidepressants. In addition, GPs are also dealing with patients suffering negative iatrogenic effects of the drugs which often lead to disability claims, health care costs, deaths and additional psychiatric diagnoses leading to further medication.
In achieving parity, does Maureen Watt hope for a Scotland where 50% of GP appointments have a mental health element? This a disturbing prospect for so many reasons.
At the meeting, a clear lack of understanding of how antidepressants work, combined with a denial of lack of training, resources and specialist services available to GPs painted a false picture of the state of mental health drug management in Scotland. At a time when one of the greatest issues facing medicine is that of dependence on and withdrawal from prescribed drugs, why is Scotland choosing to prescribe stronger for longer?
Although there is an absence of robust data to tell us the true scale of the problem, insight from charity and support groups and the ‘lived’ experience of patients tell us it is substantial. The Petition was supported by numerous submissions from individuals who were wrongly given antidepressants or benzodiazepines. They are suffering the consequences of being left on drugs without GPs with the expertise to support them through withdrawal. This is far from uncommon, as was suggested at the meeting.
Recent research and surveys detailing patient experiences show lack of prescribers’ knowledge of the key issues which should influence safer and more effective use of antidepressants. It has become abundantly clear this is an area where doctor definitely does not "know best".
It is becoming more apparent, the mainstream view that antidepressants and other drugs used in mental health work, and the processes used to establish the categories of mental disorders for which psychotropic drugs are prescribed are questionable. GPs are having to make subjective decisions about medicalising natural responses to the difficulties of everyday life.
The Minister for Mental Health has a responsibility to learn the true evidence-based facts. These include;
There are no known biological causes for any of the mental health disorders apart from dementia and some rare chromosomal disorders. There are no biological tests such as blood tests or brain scans that can be used to provide independent objective data in support of any psychiatric diagnosis.
Antidepressants have often been prescribed to patients on the basis that they cure a ‘chemical imbalance’. No chemical imbalances have been proven to exist in relation to any mental health disorder. There is also no method available to test for the presence or absence of these chemical imbalances.
Like other substances that affect brain chemistry, (such as illicit drugs), drugs used in mental health produce altered mental states. They do not ‘cure’ diseases, and in many cases their mechanism of action is not properly understood.
Studies have found that antidepressants have no clinically significant benefit over placebo pills in the treatment of mild to moderate depression, while they provide some benefit for severe depression, at least in the short term.
Recent research also suggests that antidepressants may be associated with a risk of increased mortality, at least among the elderly. There has been little research on the long-term outcomes of people taking antidepressants.
Available studies suggest that all the major classes of drugs used in mental health add little additional long-term benefit, and for some patients they may lead to significantly worse long-term outcomes.
Antidepressants can have effects that include mental disturbance, suicide, violence, and withdrawal syndromes.
Withdrawal from antidepressants can be disabling and can cause a range of severe physical and psychological effects which often last for months and sometimes years. In some cases, withdrawal charities report, withdrawal may lead to suicide.
Scotland's Chief Medical Officer's Annual Report 2014/15, "Realistic Medicine", challenges the country’s doctors to change their relationship with patients and bury the notion that the “doctor knows best” by asking them to take a look at their practice and consider if patients are being harmed by overmedicalisation. In the report, Dr Catherine Calderwood says, regarding antidepressants , “People presenting acutely unhappy to doctors are not best helped by antidepressants. Their prescription may feel that their suffering has been validated and may fulfil their expectations that the reason for their unhappiness is disease based and therefore treatable.”
In May 2017 I asked the Scottish Government if it is time to be ‘Realistic’ about the soaring prescription rates of antidepressants in Scotland……… Our already overworked GPs and the people of Scotland deserve clarity and the answer to be “Yes”.