THE ROYAL COLLEGE OF PSYCHIATRISTS IN SCOTLAND
Briefing Paper on the Pharmacological Treatment of Depression in Scotland
Background
Neuropsychiatric disorders make up about 14% of the global burden of disease. 1 In the
UK, the associated costs have been estimated to be £10.4 billion per year, and the
economic cost from lost working days is estimated to be £77 billion. Mental health
problems therefore represent a major health challenge for Scotland and antidepressant
prescribing is receiving an increasing amount of attention.
Major depression is a debilitating and common disorder, affecting between 6% and 13%
of the population during their lifetime.2,3 Anxiety disorders are at least as common,
probably affecting 14% of the population at some time.4 For both depression and anxiety
disorders, there is good evidence for both drug therapy (usually antidepressants) and
psychological/behavioural therapy (e.g. Cognitive-Behavioural Therapy; CBT). Different
people will choose different treatments, but there is reliable evidence that for many
people a combination of both is most effective; particularly in more severe or chronic
forms of depression.5,6 With mild depression, many people will opt for
psychological/behavioural treatment because the effectiveness of drugs may be less in
milder forms of the illness.
Trends in Antidepressant Prescribing
There have been increases in antidepressant prescribing throughout the UK in recent
years. In Scotland 1.26 million drugs were dispensed in 1993-94, increasing to 5.01
million in 2011/12.7 The cost to the NHS in Scotland last year was £31.3 million.
However, this is less than 50% of the total spend on lipid-regulating drugs in 2011/12;
broadly similar to the total Scottish spend on insulin; and only £5m more than the total
spend on proton pump inhibitors. Given the high prevalence and disability associated
with depression and anxiety, the cost of treatment is modest.
Treating depression
Contrary to some media reports and opinions, there is no evidence to support the claim
that psychological therapies are in some way ‘better’ or more effective at treating
depression than antidepressant drugs. The evidence would suggest that if anything,
antidepressants are at least as effective as high-quality psychological therapy 8-12 and
both have demonstrated benefit for preventing relapse. However, not all treatments will
suit everyone and a choice of evidence-based treatments is necessary for optimum
management.
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In most studies of depression in primary care, the biggest concern is not over diagnosis
of depression but under-diagnosis.13-15 Both represent contemporary challenges in
healthcare. The importance of recognising and effectively treating depression is reflected
in this being one of the few interventions that have reliably been shown to reduce suicide
at a population level.16
There isn’t any good evidence that the prevalence (i.e. how many people have a
condition at any given time) of depression has been increasing significantly over the last
10 years.17-19 People are worried about increasing rates of use of antidepressant drugs
but it is important to recognise that rates of prescription for all psychiatric (and
neurological) drugs has been going up at broadly similar rates. This probably reflects
better recognition of such conditions, greater help-seeking, and a willingness to
prescribe effective treatments when appropriate.
Understanding Trends in Prescribing
In the case of antidepressants, it is relevant that antidepressants can be used to treat
pain, anxiety, incontinence, and migraines; and increases in antidepressant use doesn’t
necessarily mean that they are being used to over-treat depression. We lack reliable
data to indicate exactly what the drugs are being used for and up until recently we can
only count the total amounts of antidepressants being dispensed.
A number of studies in recent years have confirmed what many people have long
suspected: that increasing prescription of antidepressants reflects a change in usage
(from tricyclic antidepressants to newer SSRIs) and patients receiving longer
prescriptions. Both of these changes are in line with current best-practice and evidencebased guidelines.20 Rather than more people getting drugs, a similar number of people
are getting the drugs for longer. 21 One person taking an antidepressant for six months is
a doubling in antidepressant prescribing compared to three people taking the drug for
one month. Whilst some are concerned that the effectiveness of antidepressants is low,
the effectiveness of antidepressants to prevent further episodes of depression is much
higher.22 For some people, continuing to take the drugs after getting better is an
important part of remaining well.
Antidepressants and Psychological Therapies
Many people are worried that GPs are prescribing antidepressants simply because they
don’t have access to psychological therapies. When people have looked at detail at this,
there isn’t much evidence to support such an assumption.23 Further, greater availability
of psychological therapies doesn’t seem to reduce the rates of antidepressant
prescribing;24,25 One recent study found that antidepressant prescribing increased as
psychological therapy programmes were introduced.26 This probably reflected better
recognition of common mental health disorders and importantly, such treatments tend to
be complementary rather than in competition with each other.
A number of psychological therapies have been shown to be effective for the treatment
of depression and most of these are available in Scotland. However, Scotland’s capacity
to deliver these in sufficient quantity and intensity shows regional variation, and there is
more to be done to develop a workforce able to deliver skilled psychological therapy
where it is needed. The development of the ‘Matrix’ 27 is a helpful step in supporting NHS
Boards to develop capacity and expertise in psychological and behavioural therapies and
the commitments to reducing the waiting times for such therapy will benefit patients.
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The Royal College of Psychiatrists in Scotland recognises the workforce implications for a
range of professions in ensuring that high-quality and high-fidelity psychological therapy
is embedded in Scottish mental health services. Importantly, the skills for doing this do
not lie within any one discipline and partners need to work together to increase capacity
and build expertise. The third sector is an important source of less intense interventions
and preventative approaches to mental health.
Conclusions
Few people would argue against the value of the greater availability of high-quality
psychological/behavioural therapies delivered by skilled therapists. The College supports
the commitment to reduce waiting times for psychological therapies in the Mental Health
Strategy as part of a national strategy to widen access to evidence-based psychological
therapies.
Alongside this, the use of antidepressants continues to be an evidence-based treatment
for a common disorder which is entirely appropriate for many people who are disabled by
their symptoms, and the use of drugs may actually increase the effectiveness of other
treatments by reducing someone’s symptoms to a level at which they can fully engage
with other therapies.
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