Editor’s Note: The following speech was delivered by James Davies to the UK Parliament on December 5, 2023 as part of the Beyond Pills All Party Parliamentary Group Launch.
Most people in this room will have experienced, at some point in their life, poor or very poor mental health. But if you are one of the fortunate ones who hasn’t, you’ll certainly know someone who has—a friend, a family member a close associate. And around half of those who’ve suffered a mental health problem will have at some point consulted the NHS for support.
So, what kind of support do they invariably get?
Well, when we look at the data, we learn that the majority will receive a drug prescription, and beyond that, little else. For example: In England last year around 8.5 million people were prescribed an antidepressant compared to around 1.5 million who were prescribed a psychological therapy. And this huge imbalance in provision isn’t because most people would prefer the drugs. On the contrary, we know from research that most people presenting at primary care would prefer a psychological or social provision. But that is not what they get, and it’s not what they get because, in large measure, we as a society have significantly under-invested in social, psychological, community-based intervention over recent decades. And this has created a vast gap in what we offer, which ever increasing prescribing has come to fill.
For instance, antidepressant prescriptions have almost doubled in England in the last decade, rising from 47 million in 2011 to over 85 million in 2022/23, and these figures are set to continue to rise. Furthermore, the average duration of time a person spends on an antidepressant has also doubled over the last 15 years or so, with around half of patients now classed as long-term users. Finally, if we take all the psychiatric drugs we prescribe—the anxiolytic, antipsychotics, stimulants, antidepressants—approaching ¼ of the adult population is prescribed one of these drugs in any given year.
But you may ask, what’s wrong with that—what is wrong with more people seeking help; what is wrong with more people receiving support?
Well, what is wrong is that more people are not getting better. In other words, this rising tide of prescribing (antidepressant prescribing) is not associated with an improvement in mental health outcomes at the population level. In fact, according to some measures, outcomes have worsened as antidepressant prescribing has risen (and this correlation we witness not just in the UK, but everywhere where these drugs are being most aggressively prescribed—the US, Australia, Canada, Sweden, Iceland, etc.).
Now while, of course, there may be many variables contributing to this worrying correlation, one variable occupying the concerns of a growing number of international researchers and clinicians is that such worsening outcomes are being fuelled by our over-reliance on pills, to the exclusion of much else: the social and psychological support; the community-based interventions that people need and want.
This is an especially pertinent concern when considering the efficacy of these drugs. As multiple meta-analyses have shown, antidepressants have no clinically meaningful benefit beyond placebo for the vast majority of people taking them—for all but the most severely depressed patients. However, unlike placebos, antidepressants have side and adverse effects for between 40-70% of patients, depending on the study you consult. They also have withdrawal effects for around half of users who stop them, with up to half of those reporting those effects and severe, and a significant proportion experiencing withdrawal for many weeks, months or beyond.
So when we factor in the adverse effects, the poor efficacy for most people, as well as the common sense clinical observation that most people who present at primary care with mental health problems aren’t suffering from brain dysfunctions in any biologically verifiable sense, but from natural and normal albeit painful human responses to difficult lives they are living—to difficult circumstances in which they have become caught up; circumstances that their pills were never designed to treat.
We are here today to launch the Beyond Pills All Party Parliamentary Group. A group which understands that as critical and as lifesaving medications can be, there will never be a pill for every ill (contrary to what our prescribing habits appear to imply), not just in psychiatry but across our health professions. Pills can’t save broken marriages; they can’t erase a painful past or build community. They can’t bring a loved one back. They can’t solve poverty or poor housing, or right the wrongs of inequality or discrimination, or resolve any other well-evidenced social determinant of poor health. They are what they are; they have their place. But they also need to stay in their place.
Today, we ask all of you attending to support this call to move beyond pills were appropriate; to support this parliamentary group in its activities and aspirations going forward; to challenge the institutional silos that so often inhibit change from happening, and not to stymie every good idea with the declaration: ‘but we are already doing that’ or ‘there’s already a committee for that’. The reality is that on the ground things are not changing fast enough—and we need to address that now.
As a first step to advancing change, APPG members and experts have today published a piece in the British Medical Journal, making an evidence-based call to reduce antidepressant prescribing and setting out how this can be done. In this call we align with the World Health Organisation, which only last month published its new depression guidelines. These guidelines, for the first time, demote antidepressants as a first line treatment for depression, to a subsidiary treatment, and instead put social and psychological provision first. They are calling for us to move beyond pills. We urge you all to help make that change happen.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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