The 10th of October is World Mental Health Day, and visibility of mental health is increasing across the globe. In the UK, the prevalence of depression rose from 2.2% to 2.6% from 1993 to 2007, but then further jumped to 3.8% by 2014 (Public Health England (PHE), 2019). A leading cause of global social and occupational impairment, depression is considered common, and it cost England £7.5 billion in social costs in 2007 (PHE, 2019).
A review investigating dependence and withdrawal issues associated with five commonly prescribed medicines in England has been published by PHE (2019), covering the latest evidence and highlighting patients& experiences.
The findings indicate that antidepressants in particular are being prescribed in much greater numbers and for longer durations, whereas prescriptions of benzodiazepines and opioids have fallen in recent years (PHE, 2019).
Evidence review
The review (PHE, 2019) was a response to a call from the minister for public health and primary care in 2017 for PHE to identify the scale, distribution and causes of prescription drug dependence, as well as what actions may be taken to address it. The mixed-methods public health review that was produced in response includes analysis of all NHS community prescriptions in England from 2015 to 2018, supplemented by longer-term prescription data.
Based on this review, an expert reference group provided recommendations that fell into the following five broad categories (PHE, 2019):
Antidepressant use
The PHE (2019) analysis showed that from 2017 to 2018, 11.5 million adults in England (more than a quarter of the adult population) received and had dispensed one or more prescriptions for one of the five commonly prescribed medicines in the review: antidepressants, opioids, gabapentinoids, benzodiazepines and z-drugs (PHE, 2019).
More than 60% of these people were prescribed antidepressants, equating to 7.3 million adults or 17% of the adult population (PHE, 2019). Prescriptions for antidepressants have been on the rise, particularly for longer-term treatment and especially since the introduction of contemporary antidepressants based on selective serotonin or serotonin and noradrenaline re-uptake inhibition (selective serotonin re-uptake inhibitors and serotonin and norepinephrine re-uptake inhibitors) (PHE, 2019).
Interestingly, unlike the other drugs within the scope of the review, little evidence was revealed to demonstrate any significant risk of dependence carried by antidepressants; however, patient experiences indicated otherwise. For example, one patient said:
‘I was prescribed this medication for mild sleeplessness. I became addicted to it and after 18 months of severely debilitating symptoms, the principal symptom being persistent suicidal thoughts’.
Furthermore, the review made clear the risk of withdrawal symptoms, with many reports of withdrawal when people have come off antidepressants (PHE, 2019). However, it found substantial variation between patients, as well as variations in symptom onset, degree and duration (PHE, 2019).
Supporting patients
In treating depression, the PHE (2019) review recommended that clinicians use a patient-centred approach to guide their assessment and medicine use, as well as to monitor the patient&s individual response.
The review recommended the following for health professionals, including nurses in the community who are also non-medical prescribers:
The review highlighted that patients on antidepressants, particularly over a long term, who wish to discontinue their use will probably require careful medical management and support (PHE, 2019).It noted that the rate of tapering off the medication to mitigate withdrawal symptoms should be tailored to the individual, in keeping with the recommendations of a report by Horowitz and Taylor (2019).
Conclusion
The PHE review aptly highlighted that individualised care, shared decision-making, informed choice and regular and purposeful review are all recognised as central tenets of effective clinical practice. Further, these also serve as important safeguards against people being left for too long on medication, developing dependence or experiencing withdrawal, which may outweigh the benefits derived from such medication.
The National Institute for Health and Care Excellence (NICE) is also reviewing evidence for its guideline, Depression in adults: treatment and management (NICE, 2009), which is scheduled for publication in 2020.