Antidepressants work. Why can’t we ask something more useful?

Earlier this week, The Guardian published the results of their survey, “Do antidepressants work?” Overall, responses from all five countries were remarkably similar – about 75% of people thought they did work, based on their own experiences.

This may sound exciting but actually, it’s largely a waste of time. Not only are the responses biased beyond the point of usefulness – but we already know the answer to the question.

Get some perspective

When you run a survey like this, only people who’ve had memorable experiences of antidepressants will respond – the ones who’ve had their lives transformed for better or worse. People who’ve had forgettable experiences will simply decline to fill in the form, making the results an unrealistic sample of two polarised camps.

Also, there is no guarantee that the improvements and deteriorations that people reported were due to their antidepressant. No matter how miraculous the recovery or horrific the side effect, it could’ve happened on a placebo or without a tablet at all, as part of life itself. There’s no way of telling by simply asking someone.

As a sensible scientist once said, “the world looks flat from where I’m standing”. Our own points of view are hopelessly biased, so it’s only when we look at the bigger picture that we can accurately see what’s really going on. This is why we have clinical trials – and when you look at those, the answer is clear – antidepressants work.

Even the staunchest of detractors agree. Joanna Moncrieff, who usually states that antidepressants only work via a generalised “numbing” effect, published a meta-analysis with Simon Wessely reporting that they do actually seem to work better than a “numbing” placebo. And the much debated meta-analysis of Irving Kirsch, who has written a whole book vehemently attacking the whole concept of antidepressants, suggests that they do still work in severe depression.

Of course they don’t work for everyone, no drug does. But in comparison to many other drugs in medicine, they work damn well. You’d need to give 50 people a statin to stop one of them having a non-fatal heart attack or stroke. The same number applies to aspirin. But the relapse rate in depression drops from 41% to 18% if you take tablets – the “number needed to treat” is less than 5.

In fact, an elegant paper by Leucht (2012) notes that overall, most psychiatric drugs are at least as effective as other medical drugs – but perhaps that’s a discussion for another day.

Always read the label

Sure, antidepressants have side effects, but again, so do all drugs. Here’s the side effect list for Ibuprofen, which I assume no one is debating the effectiveness of:

  • increased risk of heart attack
  • increased risk of stroke
  • nausea
  • vomiting
  • diarrhoea
  • indigestion
  • abdominal pain
  • headache
  • dizziness
  • fluid retention
  • raised blood pressure
  • gastritis
  • duodenal or gastric ulcers
  • allergic reactions
  • bronchospasm

Just because a drug has side effects doesn’t make it ineffective and certainly doesn’t justify sensationalism – just a level of caution when we prescribe it and high quality research to learn more.

Ask something more helpful

Persisting in asking if antidepressants work, when we know that they do, is an insult to those who clearly benefit from them and need them to live their lives. To tell people that they are being duped into sedation for “problems of living” by drug companies minimises their distress and devalues their right to an effective treatment. This “pillshaming” is a form of stigma which only mental health patients suffer.

We are wasting valuable time and column inches which could be spent discussing far more fruitful questions, albeit ones which wouldn’t sell papers:

  • Are we prescribing antidepressants too readily for problems that could be fixed without them – often in primary care?
  • Why is accessing talking therapy as an alternative option so difficult? Is this affecting antidepressant prescribing rates?
  • Do we discuss the indications, effects and side effects of tablets well enough with patients?
  • How close are we to tests and scans that can tell us if someone will benefit from a certain antidepressant?

We need to move on from asking if antidepressants work – and starting asking how they work best.

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The chronic underfunding of mental health care is a stigma proving hard to reverse

This article has also been published by Community Care and can be found here.

The pain, incapacity and losses involved in being ill can pose the biggest challenge many of us will ever face, but if your illness happens to be mental, the associated stigma is often what hurts the most.

This discrimination can take many forms. Recent high-profile examples of stigma being peddled by the media and elsewhere show that we’re actually seizing the opportunity to counter attack some forms of discrimination on the public stage.

Tackling high-profile stigma

Take the response to The Sun’s vile ‘1,200 killed by mental patients’ headline. Mental health charities stood on the shoulders of the misleading headline’s bigotry to provide context – that people with mental illness are five times more likely to be assaulted than average and more than 50 times more likely to kill themselves than someone else. Though The Sun’s eventual “apology”, a small clarification buried inside the newspaper, was cowardly, no newspaper will be publishing a similar headline again soon.

Likewise, Tesco and Asda were forced to withdraw offensive ‘mental patient’ fancy dress costumes after triggering a large-scale public backlash which showed that mental illness is not for anyone’s amusement anymore. Overall, that was a good day for mental health.

Granted, the victories aren’t always instant. Thorpe Park showed staggering ineptitude and insensitivity in defying calls to close or rename its offensive ‘Asylum’ attraction (where customers are chased by ‘patients’) despite a petition backed by over 5,000 signatories and a collection of mental health bodies.

Clearly the park is better at building rollercoasters than gauging public opinion, but ultimately, opposition to the attraction will continue to grow exponentially. Eventually I believe the theme park will cede their position along with a significant chunk of their reputation and through their ignorance they will have given mental health some valuable publicity.

The problem of chronic underfunding

These glaring examples are an important sign that superficial shows of stigma perpetrated in the public eye can, ultimately, be used by us to combat discrimination. Yet there is a very different, pervasive factor driving stigma that is proving harder to combat – namely the chronic lack of resources for mental health services that would be an embarrassment in any other area of health and social care.

Mental illness accounts for 23% of the total illness burden in the UK, but receives only 13% of NHS funding (added to the fact that investment in mental health has fallen in real terms for two consecutive years). Services have been so conditioned to receive barely half of what our patients deserve that we don’t even realise what a travesty it is. We’ve just learnt to put up with it.

Couple this with a pressured economic climate that is driving a growing demand for care and you’re left with a widespread crisis.

We learnt recently that nine per cent of all psychiatric beds in the UK have been closed in the past two years – more than 1,700 beds – despite rising demand. These pressures mean that the remaining NHS psychiatric wards are running at 101% occupancy – way above the recommended 85% level, with some individual wards running at up to 138% occupancy.

The pressure on beds means that, daily, doctors like myself and other mental health professionals are forced in desperation to send patients hundreds of miles away from their families to find a bed, often to private hospitals that are making millions of pounds a year from the arrangements. To someone in the depths of crisis, being sent so far from home can feel like exile, not care.

I’ve also heard of patients having to sleep on ward sofas or camp beds due to a lack of beds. Such poor care would be unthinkable in any other branch of the 21st century NHS. Even worse, in some instances, patients in crisis have been turned away from inpatient units to face their illness at home, sometimes with tragic consequences.

A crisis that demands action

In any other speciality this crisis would be worthy of front page media coverage and meaningful action by the government. Instead, all I hear of from colleagues up and down the country is talk of more cuts. This month, frontline staff in Norfolk and Suffolk have started a campaign against planned ‘cost-savings’ that they say will lead to a 20% cut in beds and caseloads rising to levels that will make safe care impossible.

When beds are closed, we’re often told that the cost savings will be invested in community teams. Yet whatever investment in community services is happening, it isn’t stemming the increase in demand for crisis care – Mental Health Act detentions topped 50,000 for the first time in 2012/13. It feels like the pressure on beds is forcing the premature of discharge of patients who simply relapse in the hands of overwhelmed community teams.

The ‘institutional bias’ against mental health in the NHS, as the care minister Norman Lamb eruditely calls it, is no less apparent in outpatient care.

The government didn’t include mental health when they decreed that 18 weeks was the deadline for seeing a consultant, making psychiatric waiting lists a low priority for commissioners. And despite the fact that depression affects two to 10 per cent of us at any one time and costs the UK nine billion pounds a year in lost productivity, access to talking therapies remains limited. Official figures show only a third of areas are meeting their 28 day target, leaving 80,000 people still waiting – many for over a year.

Trying to reduce the stigma surrounding mental illness while grossly underfunding psychiatric services during a time of growing demand is like asking children to play nicely but dressing one of them in rags.

How can we announce that mental illness is worthy of equal respect, care and understanding, when the meagre resources allocated to services by those in control of budgets perpetuate the notion that mental health care is less deserving, an optional extra that can muddle along on a pittance?

If mental health was funded as deservingly as physical health, maybe people would start treating it as such.

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