Can the Rate of Antidepressant Prescribing Be Reversed?

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From Psychology Today: “Earlier this month, a group of 27 medical professionals, researchers, patient representatives, and politicians decided to act on the data, calling for the UK government to approve guidance that would reduce and, ultimately, reverse the rate of antidepressant prescribing.

. . . The BMJ has to date published seven ‘rapid responses’ to the open letter. All but one welcome the move. Two raise concerns about the data and how it can be interpreted.

In one of the first responses, the executive to the British Society of Lifestyle Medicine writes explicitly to ‘support the call’ to reduce antidepressant prescribing: ‘Evidence suggests that over-prescribing and the harm of polypharmacy is an issue for all areas of medicine, not just for mental health.’

The BSLM adds that systematic reviews and meta-analyses of randomised controlled trials indicate that ‘interventions to improve physical activity and nutrition may be as effective as antidepressants for some people.’

In a second rapid response, Radoslaw Stupak, a psychologist and lecturer at the University of the National Education Commission, Krakow, Poland, comments on the majority of countries where antidepressant prescribing is highest: ‘What has been called “marketing-based medicine” in many cases still seems to triumph over evidence-based-medicine, not only when it comes to antidepressant prescribing.’

In the case of SSRI and SNRI antidepressants in particular, he continues, ‘Key opinion leaders repeat the old message of “safe, effective and non-addictive” drugs that save lives,’ even though the research on anti-suicidal properties of antidepressants is inconclusive and the opposite effect cannot be excluded.’

Eugene Breen, a psychiatrist and associate clinical professor in Dublin, writes in another supportive response: ‘Population dependence on mood pills looks like a fantastic marketing strategy, but it must be over-the-top and we must be missing something… The social determinants of health and mood are where we need to focus.’

Further, Anand Ramanujapuram, a psychiatrist based in Scotland stresses in his supportive response that the ‘pressure to prescribe’ is tied to reimbursement and other incentives, as well as ‘a greater increase in people seeking “medical” consultation for “psychiatric” disorders than ever before.’

Ramanujapuram spotlights an associated ‘paradox of reductionism,’ tied to this emphasis, in which the ‘brain basis for explanatory models of psychiatric conditions perpetuated in public media and elsewhere puts professionals in paradoxical positions during clinical practice.’

‘If that’s the case,’ he says of a standard follow-up question, ‘Why are you not prescribing?’

. . . In his rapid response, ‘Antidepressants do not work for very severe depression either,’ which itself indirectly addresses Hardelid and colleagues’ claim about efficacy, former University of Copenhagen professor Peter C. Gøtzsche restates that multiple meta-analyses have ‘shown antidepressants to have no clinically meaningful benefit beyond placebo for all patients but those with the most severe depression.’ He adds: ‘the fact is that the pills do not have clinically meaningful benefit for very severe depression either… The apparently larger effect in severe depression is likely just a mathematical artefact.'”

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