Rising antidepressant prescriptions and primary care mental health

Antidepressant prescriptions dispensed in England have almost doubled since 2008 (see BBC News article). Helen Stokes-Lampard, Chair of the Royal College of GPs, has responded to this recent release of prescription data by NHS Digital (see press release). She is keen that the rising rate is not necessarily seen as a "bad thing, as research has shown they [antidepressants] can be very effective drugs when used appropriately". I'm not quite sure what she means about antidepressants being effective, as I keep emphasising in this blog that the evidence is still open to interpretation (eg. see previous post).

She suggests improvement in the identification and diagnosis of mental health conditions could help to explain the rise. GPs were traditionally found to fail to diagnose up to half of cases of depression or anxiety on initial presentation (Goldberg & Huxley, 1992). Over the longer term, this figure may not be as high or as clinically important as this initial impression may suggest. Some depressed patients are given a diagnosis at subsequent consultations or recover without a GP’s diagnosis. However, there is still a significant minority of patients (Kessler et al., 2002 found 14% in their study) with a diagnosis of persistent depression that is undetected  The failure of detection of depression is commonly presumed to arise because of a lack of psychological mindedness amongst doctors. In general, doctors value objective evidence of disease more than subjective experience. This tendency creates a bias towards the over-diagnosis of physical disease, rather than the detection of mental health problems.

Maybe GPs are now treating and referring more people with anxiety/depression to mental health services, perhaps partly encouraged by the opening up of services by the development of Improving Access to Psychological Therapies (IAPT) over the last 10 years (see graph of increasing numbers of people seen by IAPT) . The number of referrals to general adult mental health services has also increased and figures suggest the number of people seen has more than doubled since 2003, excluding IAPT referrals (see tweet).

Primary care is an essential element of the provision of mental health services and has always traditionally seen more patients with mental health problems than secondary care. Helen Stokes-Lampard complains that access to alternative treatments to medication, such as CBT and talking therapies, is " patchy across the country". She says this despite the introduction of IAPT which was supposed to bridge this gap.

I want to pick up, though, the way in which Helen Stokes-Lampard seems to dichotomise the treatment of mental health problems between medication and talking therapies. In fact, most people seen by secondary mental health services do not receive psychological therapy as such. Even within IAPT, many people do not even receive short-term therapy but instead guided self-help. Polarising treatment between medication and psychological therapy forgets that much mental health treatment is social intervention - helping people understand and recover from the problems with support and becoming as independent as they are able and capable of being. GPs used to do a lot of this work with patients, perhaps particularly when there was continuity of care in general practice. But maybe primary mental health care has become more difficult with the fragmentation and dysfunctionality within health services in general over recent years.

I'm not defending a rise in antidepressant prescribing as Helen Stokes-Lampard could be said to be doing, but I agree with her that these issues - including the role of primary care in mental health treatment - need to be discussed more widely.

Overstating the impact of psychiatric research

Medium has a new mental health publication - 'Inspire the Mind' - produced by the Stress, Psychiatry and Immunology (SPI) Lab at the Institute of Psychiatry, Psychology and Neuroscience at King’ College London led by Professor Carmine Pariante, who I have mentioned previously (eg. see previous post). It has reprinted 'Facts You Should Know About Psychiatry and Why It Is Helping the Person Next to You' from a HuffPost article, although it's dropped the reference to 29 facts we should know, I think because the booklet from the Royal College of Psychiatrists to which the original article refers no longer exists (if it was ever published). Maybe the College had second thoughts about making such 'scientific' claims (eg. see previous post).

It is important to encourage debate about the potential harm of recreational drugs and whether substitute prescribing of methadone leads to harm reduction, but Pariante seems to think it is clear that cannabis causes schizophrenia, which is not the case (see eg. previous post). Like him, I also agree the development of psychological therapies should be evidenced-based, but he doesn't describe the realities of the Improving Access to Psychological Therapies (IAPT) programme (see previous post), nor mention the evidence bias towards specific therapies, such as CBT, or even the problem of the adequacy of controls in evaluating psychological therapy (eg. see previous post). Nor am I sure where his apparently inflated figure of 80% recover for psychological therapy of panic disorder and social anxiety comes from. I doubt research is really needed to show that reducing the maximum pack size of over-the-counter sales of paracetamol, and limiting sale to one pack, reduces paracetamol overdoses (although has such research actually been done?). But Pariante needs to be more careful about making claims for the value of the National Confidential Inquiry into Suicide and Homicide in improving patient safety (eg. see previous post).

I do understand why Pariante wants to answer criticisms of psychiatry. He admits himself that the article is a "little bit of PR". But his attempt to create a positive view of psychiatry shouldn't lead to him unscientifically overstating his case.