Increasing use of antidepressants in New
Zealand
Mental Health Foundation of New Zealand
Discussion paper January 2012
Introduction
There is a widely held belief amongst the public, media and government agencies that depression is a
modern-day epidemic (see Mental Health Foundation, 2012). However, there has been a counterargument that it is in fact antidepression prescription that is reaching epidemic proportions
(Summerfield 2006).
Currently, antidepressants (prescriptions to treat depression) are widely viewed internationally as the
preferred ‘first line’ response to depression, with most people seeking treatment for depression being
treated with antidepressants in the first instance (Moncrieff & Kirsch, 2005). Consequently, in New
Zealand increasing the efficiency and effectiveness of the use of antidepressants is often presented
as an important strategy for addressing the burden of mental health problems and preventing suicide,
and so this has been an on-going focus of government, pharmaceutical companies and health
consumers (Ministry of Health, 2007).
There is also a trend of increased prescribing of antidepressants in New Zealand, as internationally.
But does increased antidepressant prescription equate to improved management of depression? A
good deal of clinical literature continues to appear to assume that antidepressants are the most
appropriate (and effective) medical response to depression; however, this is contested territory. There
is on-going clinical over whether increased prescribing is a public health good (for example signifying
increased public awareness of depression, more efficient diagnosis of depression in the community
and better treatment access; e.g. Exeter, Robinson, & Wheeler, 2009) or whether current practice
amounts to ‘over- prescription’, based on an inappropriate reliance on pharmacological solutions to
depression.
In spite of the primacy of pharmacological treatment approaches, definitive knowledge of the
biochemical processes involved in depression continues to elude researchers (also see Mental Health
1
Foundation, 2012); similarly, there continues to be a lack of clinical consensus on the actual
pharmacologic mode of action of antidepressants.
This paper considers current trends in the use of antidepressants as the predominant treatment
response to depression, on-going clinical debates around the efficacy and safety of antidepressants,
and the evidence for a gradual shift towards non-pharmacological responses to depression in public
health.
Antidepressant prescription trends
Antidepressants, in particular selective serotonin re-uptake inhibitors (SSRI’s), are now among the
most widely prescribed type of medication globally (Murphy, Kremer, Rodrigues, & Schatzberg, 2003).
International research indicates a dramatically increased use of antidepressants since the introduction
of third-generation (SSRI) drugs in the early 1990s, with prescription rates continuing to rise
exponentially (Moncrieff, 2001; Gunnell & Ashby, 2004; Moore et al., 2009). For example, research
shows that antidepressant prescribing has more than doubled in the last two decades in the United
Kingdom and other Western countries, with evidence of long-term trends of increasing prescribing
since the mid-1970s (Gunnell & Ashby, 2004; Moore et al., 2009), and New Zealand data similarly
reflect a trend of increasing prescription rates (Exeter et al., 2009). As Dijkstra & Jaspers (2008, p.
149) noted, ‘All these data suggest that the increase in the use of antidepressants on a global level is
still in full progress’.
Twenty antidepressant drugs are currently approved for use in New Zealand. The most frequently
prescribed is Paroxetine (‘Aropax’), followed by Fluoxetine (‘Prozac’) (Reith, Fountain, Tilyard, &
McDowell, 2003). Ministry of Health data show that between 1997 and 2005 the number of
prescriptions for a course of antidepressants doubled (from 1.1 to 2.1 million). This increase was
largely in the prescription of SSRIs, rather than Tricyclic antidepressants (TCAs), which showed only
a small increase during this period. Similarly, the most recently available PHARMAC (personal
communication, 2011) data show a clear trend of increased prescription between 2006 and 2010 for
all age groups other than under 13 years. These increases are especially significant for the 18–24
age group (from 51,000 to 69,000), the 25–44 age group (from 246,000 to 354,000) and the 45–64
age group (from 356,000 to 498,000). Recent data indicate that around 10% of the New Zealand adult
population is currently being prescribed an antidepressant (Exeter et al., 2009; PHARMAC, personal
communication, 2011).
There are several clear trends in the available New Zealand antidepressant prescription data. Firstly,
there are obvious regional differences in prescription rates. Most notably, Canterbury District Health
Board has the highest rate of antidepressant prescription (any type) nationally, and double the rate of
SSRI prescription compared with the lowest regional rates across the Auckland District Health Boards
(Ministry of Health, 2007). Similarly, more recent PHARMAC figures show that in 2010, Canterbury
District Health Board (population 491,000) recorded 197,000 prescriptions, compared with 85,000 in
Counties Manukau (population 468,000) and 132,000 in Waitemata (population 516,000).
There are also significant differences in prescription rates between ethnic groups, with considerably
higher rates for New Zealand European than for both Māori and Pasifika groups. This is consistent
with previous research, which has found that Māori are less likely than non-Māori to be treated with
antidepressants (Arroll, Goodyear-Smith, & Lloyd, 2002) and that there is lower access to mental
2
health treatment more generally among Māori and Pasifika peoples (Baxter, Kokaua, Wells, McGee,
& Browne, 2006).
In considering overall antidepressant prescription rates in New Zealand, it is important to recognise
that antidepressants (in particular SSRIs) are also commonly used to treat anxiety. Anxiety disorders
are the most common mental health problem in New Zealand (14.8% 12-month prevalence), followed
by mood disorders such as depression (7.9%) and substance abuse (3.5%) (Oakley Browne, Wells, &
Scott, 2006). It is therefore worth noting the significance of antidepressant prescriptions for anxiety
disorders in contributing to the overall volume of antidepressant prescriptions in New Zealand.
There is limited local research on antidepressant prescription practices in New Zealand, and available
data are not currently linked to clinical information, such as the reason for prescription (e.g. for
anxiety). Therefore, further research into the use of antidepressants, for example in the specific
treatment of anxiety (Exeter et al., 2009), the duration of prescribing and the doses prescribed would
be useful.
Do antidepressants ‘work’?
In recent years, significant public health efforts have aimed to address the burden of depression. In
New Zealand, as in other countries, this has included the launch of awareness campaigns targeting
depression, the development of suicide prevention strategies, and the introduction of primary care
practitioner guidelines for the treatment of depression and other mood disorders.In the last two
decades, new generation antidepressants have also been developed, which are marketed as clinically
superior to older antidepressant types and widely endorsed as an appropriate first-line response to
depression. However, it is not clear whether the apparent exponential increase in antidepressant
prescriptions will counter the often-cited predictions that the global burden of depression will increase
to become the second leading contributor to the global burden of disease (DALYs; Disability Adjusted
Life Years) for all ages and both sexes by 2020. According to WHO (2011), ‘Today, depression is
already the 2nd cause of DALYs in the age category 15–44 years for both sexes combined’.
There appears to be little evidence that increasing the availability of antidepressants results in an
overall reduction in mortality and morbidity associated with depressive disorders. Depression is
increasingly recognised as a chronic condition with a tendency to recur (Simon, 2000; Andrews,
2001). As Dobson et al. (2008) noted, there is little evidence that antidepressants alter the course of
depression, and there is a well-known risk of relapse once medication is withdrawn. The value of
antidepressants in suicide prevention is also subject to debate, as clinical trials have not
demonstrated that those taking antidepressants are less likely to attempt suicide than those receiving
a placebo (Khan, Warner, & Brown, 2000) As Moncrieff and Kirsch (2005, p. 157) noted,
‘Antidepressants have not been convincingly shown to affect the long term outcome of depression or
suicide rates’. Thus, evidence about the limited efficacy and therapeutic benefit of antidepressants
has raised questions about the extent to which drug therapy alone can be relied upon as a response
to depression.
Since SSRIs were introduced in the 1990s, they have been medically promoted and marketed by
industry to the public as drugs that have a specific effect on chemical pathways in the brain. Thus, the
popularity of antidepressants can be seen to rest on an assumption that the drugs ‘work’ by having an
active biochemical effect on the brain. However, within the clinical sphere, biochemical theories of
3
depression are recognised as unproven (Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999;
Greenberg, 2010). A number of meta-studies have highlighted the significance of the placebo effect,
and raised many questions about the extent to which antidepressants ‘work’ in a chemical sense. For
example, in a meta-analysis of both published and previously unpublished trial data, Kirsch, Deacon,
Huedo-Medina, Scoboria and Johnson (2008) found that SSRIs did not produce clinically significant
differences from placebos in treating mild to moderate depression; a similar finding was made by
Fournier et al. (2010). Both studies did note a clinically significant benefit of antidepressants over
placebos in the treatment of severe depression, however. On the basis of these findings, the authors
recommended that antidepressants should only be used when an alternative (i.e. non-drug) approach
had been tried and failed, rather than as a first line response (Kirsch et al., 2008). Furthermore, as
Moncrieff (2001, p. 293) has argued, ‘The fact that depressive conditions respond to a variety of
psychotherapies also implies that recovery is not achieved through a particular biochemical
manipulation’. However, other meta-analyses support the efficacy of antidepressants over and above
placebos even for less severe forms of depression (see, for example, Arroll et al., 2009).
The measurement of what constitutes a clinically significant pharmacological effect is also a hotly
debated issue (NZGG, 2008). Historically, randomised controlled trials (RCTs) were regarded as the
‘gold standard’ method for establishing the effectiveness of drugs such as antidepressants. However,
in recent years, the previously accepted evidence base for the efficacy of antidepressants has come
under clinical scrutiny, with some researchers arguing that early RCTs demonstrating the superiority
of antidepressants over placebos were methodologically flawed, with a bias towards reporting on only
positive findings, and so reliance on their findings results in continued overstatement of the efficacy of
antidepressants (Moncrieff, 2001; Ministry of Health, 2007, p. 1; Mental Health Foundation, 2012).
Pharmaceutical sponsorship of these clinical trials (and the withholding of unfavourable results) is
seen as a further problem with the reliability of the current evidence base on antidepressants (Kirsch,
Moore, Scoboria, & Nicholls, 2002; Kirsch et al. 2008).
Thus, not only is there a lack of clinical consensus about the causality of depression, but there also
appears to be a substantial gulf between public and clinical understanding of how antidepressants
‘work’ and the existing caveats on their efficacy.
The context of antidepressant prescription in New Zealand
In New Zealand and internationally, increases in antidepressant prescription have been attributed to
an increased awareness of depression (both by clinicians and the general public), as well as the
expanding range of conditions for which antidepressants are now prescribed, including anxiety,
seasonal affective disorder and premenstrual syndrome (Hollinghurst, Kessler, Peters, & Gunnell,
2005). Further explanations have included lower prescription thresholds, stricter adherence to clinical
guidelines leading to longer courses for first prescriptions, and an increasing rate of repeat
prescriptions for chronic depression (Moore et al., 2009).
While global trends of increasing prescription rates would seem to reflect a generalised clinical
endorsement of the widespread use of antidepressants, clinical guidelines for practitioners
increasingly include caveats on their use, citing recent evidence relating to limitations, risks and
alternatives to antidepressants. For example, the most recent National Institute for Health and Clinical
Excellence (NICE) guidance on the management of depression advises against the use of
antidepressants in the first instance for mild depression due to a poor risk-benefit ratio (NICE, 2009).
4
Instead, it is advised that individuals with mild to moderate depression be offered a range of ‘low
intensity psychosocial interventions’, including guided self-help (based on CBT principles),
computerised cognitive behavioural therapy (CCBT), and a structured physical activity (NICE, 2009).
New Zealand practitioner guidelines similarly recommend a conservative approach to the use of
antidepressants in cases of mild to moderate depression (see, for example, NZGG. 2008, p. xv),
which states that ‘psychological and pharmacological therapies are equally effective for treating adults
with moderate depression’.
International research suggests that while many GPs regard antidepressants as being of limited value
and would prefer to refer patients with mild depression for non-drug therapies (including exercise
therapy), they are primarily constrained due to limitations in availability and funding (Mental Health
Foundation UK, 2005). This may go some way to accounting for the continuing trend of increasing
prescription. Other research conducted by an independent medical research company in the United
Kingdom found that 80% of GPs admitted to over-prescribing antidepressants, with three-quarters of
GPs surveyed stating that they were prescribing more antidepressants than they did 5 years
previously. GPs cited a lack of availability of psychological therapies for managing mild to moderate
mental health conditions as the primary reason for this (Norwich Union Healthcare, 2004). Thus, while
clinical guidelines increasingly encourage practitioners to take a cautious approach to prescribing and
endorse encouraging the use of evidence-based alternatives, in reality many clinicians are not wellplaced to refer their patients to these treatment approaches, which do not currently receive the same
level of subsidisation as drug treatments.
Similarly, it is likely that New Zealand’s antidepressant prescription trends to some extent reflect a
historical lack of access to alternative treatment approaches for depression, as prescriptions for
antidepressant medication are heavily subsidised by the Government, while other approaches often
require that users pay the full cost – and time with a private, experienced and qualified therapist or
counsellor can cost around $100–150 per hour. The limited availability of psychological therapies in
New Zealand is now being recognised (e.g. Peters, 2007; Te Pou O Te Whakaaro Nui, 2009) and
there have been recent moves to increase access to these services within the primary care setting.
There is not currently the provision for general practitioners to refer patients for subsidised depression
counselling, however. Although the total funding is $23m per year, this does not cover every general
practice and tight criteria are applied by each Primary Health Organisation (PHO) to ensure that the
services offered are provided to those in highest need (Ministry of Health, email correspondence, 23
December 2011).
In addition to referrals to private therapists or counsellors, a variety of other initiatives are also in
place. This includes an 8-week computerised cognitive behavioural therapy (cCBT) programme called
‘Beating the Blues’, which has been funded since February 2011 and in which GPs can enrol their
patients. There is also an online interactive tool for individual self-management of mild to moderate
depression (‘The Journal’). With an increasing number of New Zealanders now online (86% in 2011;
www.aut.ac.nz/research/research-institutes/icdc/projects/world-internet-project, retrieved 11 January
2012), this will be an option for most New Zealanders.
Mental health problems are commonly seen in the primary care (i.e. general practice) setting and are
clinically recognised as a major cause of disability in the general population (NZGG, 2008). The
Ministry of Health (2008, p. 1) noted that ‘Mental disorders are extremely common in the general
practice setting, with over one third of adults attending primary care likely to have met the criteria for a
DSM-IV diagnosis within the past 12 months’. It is increasingly recognised that the burden of disease
5
associated with depression vastly exceeds the capacity of specialist services. As Lillis, Mellsop and
Dutu (2008, p. 30) noted, ‘Recognition of this mismatch between total community psychiatric morbidity
and available specialist resources has led to worldwide commitments to increasing the delivery of
skilled mental health care within the setting of primary care’. Following this view, the primary care
setting is increasingly being recognised as an appropriate forum for initiatives in mental health care
and promotion in New Zealand. The development of primary mental health initiatives also reflects the
Goals of the Primary Health Care Strategy (Ministry of Health, 2001) as a strategic approach with an
emphasis on population health, health promotion/preventive care and community-led initiatives
(Dowell et al., 2009).
The general practice setting is also recognised as important for the early recognition of mental health
problems, due partly to the continuity of contact between patients and their GP (Reid, 2005). The
Ministry of Health (2008, p. xv) noted that ‘Routine psychosocial assessment is the key to improving
the recognition of common mental disorders’, and general practitioners are increasingly seen as
ideally placed to detect and treat mental illness at an early stage. Other recognised benefits of a
primary care approach to mental health care include affordability and accessibility of treatment, the
capacity for health promotion, and the potential for integration of physical and mental health care in
terms of offering a more holistic package of care (Dowell et al., 2009). GPs act as a ‘gateway’ to
mental health services in New Zealand, with the exception of crisis presentations (MaGPIe Research
Group, 2005). The majority of individuals with mental health problems in New Zealand will access the
healthcare system via their GP and have their problem managed in that setting, with some patients
referred from there to secondary or tertiary settings (Reid, 2005). New Zealand literature suggests
that GPs deliver around three-quarters of the treatment for mental health disorders in New Zealand
(MaGPIe Research Group, 2003).
A 2003 study undertaken by the MaGPIE (Mental Health and General Practice Investigation
Research) group at the University of Otago found that 36% of those attending their GP had one or
more of the three most common mental health problems – anxiety, depression and substance
use/dependence (in descending order of frequency), with a frequent occurrence of co-morbidity
(MaGPIe Research Group, 2003). This research noted a reluctance among patients to disclose
psychological problems to their GP, with the vast majority of patients with mental health issues not
presenting this to their GP as the main reason for their appointment. Surveyed GPs felt that roughly
half of those attending had experienced some degree of psychological problems in the previous year,
although not necessarily at the level of diagnosis. In New Zealand, these mental health problems are
not evenly distributed in society, with certain ethnic groups (specifically Māori and Pasifika peoples)
having markedly higher rates of mental health problems (Dowell et al., 2009).
In New Zealand, barriers to the effective use of GPs in depression care (including cost effectiveness)
have been increasingly recognised within the public health sector in recent years. A number of
measures have been proposed and trialled for improving GP knowledge and skill in depression care,
as well as for increasing public ‘mental health literacy’ and de-stigmatisation of mental illness
(MaGPIe Research Group, 2005, p. 634).
The primary mental health initiatives currently being implemented in New Zealand, including the
provision of a short course of talking therapy sessions, have been positively evaluated and well
received by consumers (Dowell et al., 2009). A large, unmet need for psychotherapeutic intervention
in primary care has been noted. Given the prohibitive cost of private counselling in New Zealand, it
would be valuable to extend existing primary mental health counselling initiatives to allow access to a
6
greater proportion of the general population. Through broadening access to non-drug therapies for
depression, this may conceivably result in a reduction in the national antidepressant prescription rate.
Risks associated with antidepressants
In the literature, side effects are reported to be a very significant problem associated with
antidepressant use, with 30–60% of those prescribed antidepressants discontinuing treatment for this
reason (Antonuccio et al., 1999). Hu et al. (2004) found that clinicians tend to underestimate how
troublesome these side effects are for their patients. SSRIs are often prescribed in preference to other
antidepressant types because they are considered to be safer in terms of adverse effects and
consequences of overdose (Wessley & Kerwin, 2004; Exeter et al., 2009). However, unpleasant side
effects including sexual dysfunction and drowsiness (Hu et al., 2004), sleep disturbance (Armitage,
2000; Ferguson, 2001), weight gain (Mansand & Gupta, 2002), and gastro-intestinal problems such
as nausea are still widely reported and experienced by up to 50% of patients using SSRIs
(Antonuccio et al., 1999; Ferguson, 2001). Unpleasant withdrawal symptoms (i.e. discontinuation
syndrome) are also a well-documented issue for all antidepressant types, including SSRIs (Ferguson,
2001).
Over and above the occurrence of troublesome side effects, a safety concern related specifically to
SSRI use is the risk of drug reactions, specifically serotonin syndrome. This reaction causes the body
to produce too much serotonin, resulting in potentially life-threatening symptoms, including increased
heart rate, delirium, overactive reflexes and agitation, increased body temperature, and hallucinations
(Boyer & Shannon, 2005). There is greatest risk of the syndrome when first starting an SSRI, when
other drugs are being taken alongside SSRIs, when medications are changed, and when there is
intentional or unintentional overdose (Ferguson, 2001). While SSRIs are considered to be a safer
class of antidepressant than older types, Antonuccio et al. (1999) reported that they are frequently
(more than 50% of the time) prescribed alongside other psychotropic medications, resulting in
increased risk of reactions such as serotonin syndrome.
Other safety concerns associated with antidepressant medication relate to associated risks of suicide,
suicidal ideation and intentional self-harm. There appears to be widespread clinical support for the
value of antidepressants in preventing suicide, with a view that increasing the use of antidepressants
will result in a reduction in the suicide rate (e.g. Exeter et al., 2009; Mulder, Joyce, Frampton, & Luty,
2008). Ministry of Health research on antidepressant prescription patterns in New Zealand supports
this, noting a significant decline in suicide rates since the introduction of SSRIs (Ministry of Health,
2007). However, international literature in this area shows ongoing debate about the evidence base
for the value of antidepressants in suicide prevention, with some arguing that a conclusive link has not
been demonstrated (e.g. Khan et al., 2000; Safer & Zito, 2007). Antidepressants are also the
medication most commonly used in suicide by poisoning (Kapur, Mieczkowski, & Mann, 1992), with
the most recent available New Zealand data citing coronial records for 2001, which showed that 200
poisoning deaths were directly attributable to, or involved, antidepressants (146 intentional and 54
unintentional deaths) (Reith et al., 2003). It should be noted that SSRI medications are less likely to
be lethal in overdose than other types; nonetheless, the literature notes an ongoing concern about
possible links between SSRI use and suicide and self-harm. Of particular concern has been the
question of increased risk for children and adolescents. In New Zealand in 2004, the medicines
regulatory authority MEDSAFE advised the prescriber of an unfavourable risk/benefit ratio for
prescribing SSRIs (other than Fluoxetine) to children and adolescents (MEDSAFE, 2004). This
7
followed the issuing of a statement by the US Food and Drug Administration requiring antidepressant
labelling to indicate increased risk of suicide, particularly in these groups; subsequently in 2005, a
further advisory was issued about the need to closely monitor adults taking SSRIs for suicidal
thoughts. Clinical protocols now tend to advise against the use of antidepressants as a first-line
approach in treating depression in children and adolescents; however, there is ongoing debate with
respect to suicidality and use in adults.
Moncrieff and Kirsch (2005) noted that meta-analyses of data from antidepressant drug trials have not
found any difference in suicide rates between drug and placebo groups, and Didham, McConnell
Blair, & Reith (2005) did not find a direct link between SSRI use and suicide in New Zealand, and
suggested that causality is complex and more likely related to the underlying condition: ‘Overall the
results of this study suggest that the more depressed patients are prescribed SSRIs, therefore these
drugs appear to show a greater risk of self-harm and suicide. However the real risk factors are more
likely to be depression and suicidal ideation’. However, this research and the Ministry of Health (2007)
study did note a statistically significant association between increased prescription rates of SSRIs and
increased rates of hospitalisation for intentional self-harm in New Zealand. Fluoxetine, one of the two
most widely prescribed SSRIs, was shown to be associated with the highest increased risk of
hospitalisation for intentional self-harm, with the Ministry’s figures showing that in 2005, 3113 of the
80,829 patients being prescribed Fluoxetine were hospitalised (Ministry of Health, 2007). This
increased risk of self-harm may not be widely recognised in the public domain as a significant risk
associated with SSRI use.
Another area of risk noted in the literature relates to health risks associated with long-term
antidepressant use. Long-term prescription rates are significantly higher than in previous decades,
and appear to account for a substantial amount of the overall increase in prescribing (Moore et al.,
2009). Indeed, individuals with recurring depression are often encouraged to remain on medication
indefinitely (Dobson et al., 2008). A study by Cruickshank et al. (2008) found that more than half of
the patients on longer-term antidepressants did not meet the criteria for a psychiatric diagnosis,
raising the question of the need for on-going review in cases of long-term prescribing. Related studies
similarly have signalled concerns over inadequacies in clinical review in cases of long-term
prescribing (Petty, House, Knapp, Raynor, & Zermansky, 2006; Leydon, Rodgers, & Kendrick, 2007).
Research suggests that, in some cases, individuals may wish to stay on antidepressants to avoid
withdrawal effects, or due to a lack of clinical encouragement/support to discontinue their medication
(Petty et al., 2006; Leydon et al., 2007; Moore et al., 2009).
While repeat, long-term prescribing is used as a strategy to manage the problem of recurrence,
evidence is emerging that long-term use may actually have a ‘pro-depressant’ effect in some
individuals, causing permanent, treatment-resistant depression (Fava, 2003; El-Mallakh, Gao,
Briscoe, & Roberts, 2010; Andrews et al., 2011; El-Mallakh, Gao, & Roberts, 2011). This proposed
syndrome of drug-induced chronic depression is termed tardive dysphoria or oppositional tolerance. It
is thought that irreversible changes to drug receptors in the brain occur after long-term use, causing
the brain to make compensatory adaptations to restore normal functioning, resulting in increased
biochemical vulnerability to depression thereafter.
Given the growing clinical consensus that antidepressants offer no significant clinical benefit in cases
of mild to moderate depression, the emerging evidence about the risk of antidepressant use inducing
chronic depression adds compelling weight to the view that antidepressant therapy should, if possible,
be avoided as a first-line response to less severe types of depression. It has also been suggested that
8
where antidepressants are prescribed, guidelines for maintenance therapy (i.e. to prevent relapse
after resolution of the initial acute episode) should be reviewed in light of such risks (Andrews,
Kornstein, Halberstadt, Gardner, & Neale, 2011). Evidence of a dramatic increase in antidepressant
treatment resistance since the 1990s (El-Mallakh et al., 2010) suggests that repeat prescription is
probably widespread, and so there is potential for a large number of cases of untreatable druginduced chronic depression to emerge as a serious public health issue in the future.
Evidence-based alternatives to antidepressants
Prior to the advent of widespread antidepressant use, psychotherapeutic approaches were a
significant component of psychiatric practice in North America (Greenberg, 2010). However, there has
been a continued decline in the availability of psychotherapy as a treatment option (Olfson & Marcus,
2010). While popular demand for antidepressants is often cited as having fuelled increasing
prescription rates, evidence suggests that those on the receiving end of depression treatment
generally have a strong preference for talking therapies and self-help approaches over drug
treatment, and consider these approaches to be highly effective (Antonuccio et al., 1999; Jorm, 2000;
van Schaik et al., 2004). As van Schaik et al. (2004) noted, part of this preference relates to a view
that talking therapies address the core reasons for depression, while antidepressants have
unpleasant side-effects and a risk of addiction.
For the treatment of more severe forms of depression, there is a clear evidence base for the value of
medication, with meta-analyses confirming clinically significant benefits over placebos (Kirsch et al.,
2008; Fournier et al, 2010). However, psychological therapies, in combination with drug treatment, are
still recognised as having a valuable role even when treating severe depression, with clinical protocols
stating that a combined approach is more useful than medication alone (NICE, 2004).
Psychological therapies are now well-recognised as being effective in treating a range of mental
health problems, including depression, anxiety, addiction and social phobias, and this approach is
widely endorsed within the mental health sector (Mental Health Foundation UK, 2006; Mental Health
Commission, 2007). This endorsement is underpinned by a substantial and ever-increasing scientific
evidence base for non-pharmacological approaches to depression care, in particular cognitive
behavioural therapy (CBT), which currently has the largest body of scientific support. Such treatment
is now recognised as being equally effective to antidepressants in the treatment of mild to moderate
depression (Mental Health Foundation UK, 2008; NZGG, 2008; Exeter et al., 2009; Segal et al.,
2010); for a review of relevant literature, see DeRubeis and Crits-Christoph (1998). Mindfulness is
another emerging evidence-based practice that can be learned in group settings, and which can
reduce symptoms of depression and anxiety, decrease risk factors such as chronic psychological
stress, and be a protective factor for future mental health (Mental Health Foundation, 2011).
A key therapeutic benefit of pshychological therapies over drug treatment is their long-lasting effect
and value in preventing relapse of depression (Fava, 2004; Hollon et al., 2005). A 2006 meta-analysis
on CBT showed that depression relapse rates for those treated with CBT were half that of those
treated with drugs alone (Butler, Chapman, Forman, & Beck, 2006). Occupational health research
also shows that CBT helps people with depression to stay in employment (Seymour & Grove, 2005).
Another benefit of non-pharmacological approaches is the avoidance of side effects (Antonuccio et
al., 1999), which, as noted earlier, may not be well-recognised by clinicians as a problem for those
taking medication.
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However, despite the available evidence base for psychological therapies, historically there have
been several barriers to the integration of these approaches into mainstream depression care.
Psychological therapies have often been viewed as having an unfavourable cost-benefit ratio
compared with medication. However, there is some evidence to suggest that approaches such as
CBT are more cost-effective in the long term, as they have longer lasting benefits than medication
(Antonuccio, Thomas, & Danton, 1997; Hollon et al., 2005; Dobson et al., 2008). As Bosmans et al.
(2008) noted, there is growing evidence that the overall cost-effectiveness of treatment for depression
could be improved by wider use of these treatments.
Psychological approaches also do not currently have comparable scientific or popular status or
credibility to antidepressants as an effective treatment for depression (Greenberg, 2010). Clinical
advocates for the value of psychological therapies continue to argue that the current landscape of
depression treatment has been substantially shaped by the interests of pharmaceutical companies,
through sponsorship of drug research and trials, selective publication of trial results, and more broadly
through historic involvement in the framing of depression as a biochemical problem (Moncrieff, 2008;
Greenberg, 2010. (See Mental Health Foundation (2012) for further discussion around the aetiology
of depression and its treatment.) This, arguably, accounts for the continued ideological and financial
bias towards pharmacological responses to depression, which, in turn, may be reflected in a lack of
institutional will to implement the necessary infrastructure for ‘mainstreaming’ psychological therapies.
As Hollinghurst et al. (2005) have suggested, ‘Increases in the pharmacological treatment of
depression have not been matched by the development of psychological services of proved
effectiveness, which may reflect the absence of a powerful body, equivalent to the pharmaceutical
industry, to promote their development and use’. Within New Zealand, although CBT is endorsed as
effective and recommended to be delivered in the primary care setting by a range of practitioners
(Mental Health Commission, 2007), access to CBT and other evidence-based psychological therapies
is still very limited and, when available, is recognised as extremely variable in terms of regional
availability, practitioner training level and cost of service (Mental Health Commission, 2007).
In other countries, GP referral to psychological therapies is receiving substantial funding boosts. For
example, in the United Kingdom, NICE has recommended that a range of psychological therapies be
made available on the National Health Service (NHS), and in 2011 the United Kingdom Government
announced plans to substantially increase the availability of free psychological therapies on the NHS,
making available a choice of several different approaches (CBT, Counselling for Depression and
Interpersonal Therapy), and also allowing for self-referral by GP patients (NICE, 2011). This amounts
to an investment of ₤400 million in addition to existing funding. Similarly, Australia and Scotland plan
to increase investment in the use of talking therapies in both primary and secondary care (Mental
Health Commission, 2007). Within New Zealand, there is consensus among clinicians and service
users that further improved access to psychological therapies is needed (RANZCP, 2004; Peters,
2007; Te Pou O Te Whakaaro Nui, 2009), and recognition of the need for development and
expansion of such services in the primary care setting (Dowell et al., 2009). More substantial
investment into increasing the availability of free or subsidised psychological therapies via PHOs at a
national level in New Zealand would, therefore, seem timely.
10
Conclusions
This paper raises questions about whether current levels of antidepressant prescribing are
scientifically justified. This is an area of ongoing scientific and clinical debate, but such questions have
only recently begun to be aired in the public domain. It is clear that the popular view of depression as
fundamentally a medical problem, i.e. due to a chemical imbalance and requiring a chemical
response, rests on an evidence base that is subject to ongoing debate within the clinical domain, as it
continues to exclude a large body of data on proven alternatives to medication, and reflects an
ongoing lack of intellectual and financial investment in this area. This means that currently many
people with depression may not be receiving the help that best fits their needs, and additionally may
be being exposed to side effects and health risks. Given the current lack of access to non-drug
treatments, and the evidence relating to the risks and side effects of antidepressants, it is possible
that the high rates of antidepressant prescription in New Zealand may be more a result of a lack of
availability of alternatives rather than the efficacy or tolerability of these drugs. There is also evidence
that consumers would often prefer non-pharmacological treatments for depression. Guidance for New
Zealand GPs in treating depression states that ‘planned treatment for depression should reflect the
individual’s values and preferences and the risks and benefits of different treatment options’ (NCGG,
2008, p. xv); for this commitment to take pragmatic effect, current funding would need to be extended
so that talking therapies could be made available in the primary care setting to all GP patients.
Meta-analyses of SSRI drug trials demonstrate a lack of significant clinical benefit in the use of
antidepressants to treat mild to moderate depression. Nonethless, in New Zealand and internationally,
prescription rates continue to increase, suggesting an urgent need to re-evaluate the public health
gains of antidepressants in reducing the individual and social burden of depression, and to consider
the apparent disconnect between evidence base, clinical protocols and clinician prescription practices
‘in the field’. Similarly, increased public awareness of the drawbacks of antidepressants may be
required to challenge prevailing popular beliefs about the superiority of drug therapies over other
evidence-based treatments for depression. Recent initiatives to strengthen the primary mental health
sector in New Zealand offer a timely opportunity for public education in this area.
There is evidence that Māori and Pasifika peoples are less likely to access mental health services in
New Zealand. Targeted funding for psychological therapies would be a positive attempt to address
such inequalities in mental health outcomes in this country. In addition, the fact that these groups
receive antidepressant treatment for depression far less frequently than European/Pākehā New
Zealanders may offer an interesting opportunity to observe the value of psychological approaches in
this group in comparison with other groups. An evidence-based approach to the treatment of
depression suggests that extending these initiatives to the general population would result in
significant public health gains, by relieving the individual and social burden of depression in New
Zealand, and reducing morbidity associated with antidepressant use.
11
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