A review investigating dependence and withdrawal issues associated with five commonly prescribed medicines in England has been published by Public Health England (PHE), reviewing the latest evidence and highlighting patients' experience. As World Mental Health Day approaches on 10 October, findings indicate that antidepressants in particular, are being prescribed in much greater numbers and for longer durations, whereas prescriptions of benzodiazepines and opioids have fallen in recent years (PHE, 2019).
Evidence review
The PHE (2019) review was a response to a call from the Minister for public health and primary care in 2017 for PHE to identify the scale, distribution and causes of prescription drug dependence, and what actions may be taken to address it. The mixed-methods public health review, which was produced in response includes analysis from PHE of all NHS community prescriptions in England from 2015–2018, supplemented by longer-term prescription data. It also includes an independently commissioned rapid evidence assessment of articles published in the 10 years between 2008 and 2018 on prescription medicine-associated harms, withdrawals, risk factors and service models, and documents summarising patients' experiences of taking these medicines and of treatment services (PHE, 2019).
An expert reference group then discussed the findings and advised on recommendations. These recommendations fell into the following five broad categories (PHE, 2019):
- Increase the availability and use of data on the prescribing of medicines that can cause dependence or withdrawal to support greater transparency and accountability and help ensure practice is consistent and in line with guidance
- Enhance clinical guidance and the likelihood it will be followed
- Improve information for patients and carers on prescribed medicines and other treatments, and increase informed choice and shared decision-making between clinicians and patients
- Improve the support available from the healthcare system for patients experiencing dependence on, or withdrawal from, prescribed medicines
- Conduct further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines.
Depression and antidepressants
In the UK, the prevalence of depression rose from 2.2% to 2.6% in the 14 years from 1993 to 2007, but further jumped to 3.8% by 2014.
A leading cause of global, social and occupational impairment, depression is considered common, and cost England £7.5 billion in social costs by 2014. In treating depression, the PHE review recommends that clinicians use a patient-centred approach to guide their assessment and medicine use, as well as to monitor the patient's individual response (PHE, 2019).
The PHE (2019) analysis shows that from 2017 to 2018, 11.5 million adults in England (more than a quarter of the adult population) received (and had dispensed) one or more prescriptions for one of the five commonly prescribed medicines in the review: antidepressants; opioids; gabapentinoids; benzodiazepines and z-drugs (PHE, 2019). However, more than 60% of these people however were prescribed antidepressants; that is 7.3 million adults or 17% of the adult population (PHE, 2019). Prescriptions for antidepressants have been on the rise, particularly for longer-term treatment and especially since the introduction of contemporary antidepressants based on selective serotonin or serotonin and noradrenaline reuptake inhibition (SSRIs and SNRIs) (PHE, 2019).
Interestingly, unlike the other drugs within the scope of the review, little evidence was revealed to demonstrate any significant risk of dependence carried by antidepressants; however, patient experiences indicated otherwise. For example, one patient said:
‘I was prescribed this medication for mild sleeplessness, but I became addicted. 18 months on, I had debiliating symtoms, the most prominent of which was suicidal thoughts‘.
Furthermore, the review made clear the risk of withdrawal symptoms, with many reports of withdrawal when people have come off antidepressants (PHE, 2019). There is reported to be substantial variation between patients, however, as well as variability of symptom onset, degree and duration (PHE, 2019).
Patient experiences
The review includes many examples from the literature of patient experience. Some people taking antidepressants felt that the treatment is worse than the illness, with patients reporting:
‘I don't believe I will ever again be the productive, happy, sociable person I used to be because of one 10 minute appointment where a GP decided it was appropriate to prescribe me SSRIs with no warning of possible side effects.’
‘I was fully functioning working full time as an accountant, several staff under me, driving socialising, dating - fully normal life. All taken away from me, driving included.’
Patients describe many physical and severe emotional and mental side effects. They report an overall negative impact on their lives, including relationships, social life and work (PHE, 2019). One participant who experienced a numbing of all emotions, positive and negative, said:
‘There came a point where, alright, I've survived, but what's the point in surviving if you can't feel?’
People with more severe depression appear to have a more favourable experience of antidepressant treatment than people with less severe depression as the impact of the medication on severe depression can be transformative but there are arguments for and against their efficacy in less severe cases (PHE, 2019). Participants on antidepressants also reported feeling a sense of ‘not being normal' as a result of the difficulties associated with taking medications.
Supporting patients
In the PHE review, it is recommended that prescribers:
- Consider all treatments that may work for a patient, including those that don't involve (or in addition to) medications, such as talking therapies, physical exercise and other social prescriptions
- Tell patients clearly about the risks and benefits of medicines
- Regularly review whether a medicine is in fact helping a patient or not, including any side effects which may outweigh any benefit being derived from the medications (as in some of the patient examples)
- Change the treatment appropriately and safely if it doesn't appear to be helping the patient.
The review highlights that patients on antidepressants, particularly over the longer term, who wish to discontinue their use will likely require careful medical management and support (PHE, 2019). The review notes that the rate of tapering off the medication to mitigate withdrawal symptoms should be tailored to the individual according to a report by Horowitz and Taylor (2019).
Conclusion
The recently published PHE review aptly highlights that individualised care, shared decision-making, informed choice, and regular and purposeful review are all recognised as central tenets of effective clinical practice; and that they also serve as an important safeguard against people being left for too long on medication, developing dependence or experiencing withdrawal (which as mentioned may outweigh benefits derived from such medication).
Antidepressants are often prescribed over the longer term, sometimes to prevent relapse to depression (PHE, 2019). This can be clinically appropriate in some circumstances; however, for others, it may not be the best option and social prescriptions may well be more appropriate for less severe cases. Antidepressant prescriptions come with important considerations such as side effects of the medication, impact on a person's quality of life and the risk of withdrawal symptoms when the patient attempts to taper off the medication in future. The importance of regular patient reviews, active listening and appropriate action in response to a patient's concerns cannot be overestimated.
The review recommends better monitoring, treatment and support for patients being prescribed the five medications including antidepressants (Robinson, 2019), as patient reports indicate fear of not being supported by health professionals, as well as sometimes ambivalence and lack of clarity regarding why they are still on their medication over the long term.
Equally, however, it must be noted that it is not appropriate to stigmatise the appropriate and safe use of potentially helpful medicines or inappropriately curtailing or limiting their use, which may increase harm, including the risk of suicide (PHE, 2019). Poorly managed or blanket ‘deprescribing', with inadequate support could also lead to people seeking medicines from illicit or less-regulated sources, and/or resorting to illicit drugs to treat symptoms or prevent withdrawal (PHE, 2019).
The review recommends setting up a national helpline to provide patients with support and guidance regarding tapering, coping with withdrawal, and other such issues (Robinson, 2019). The National Institute for Health and Care Excellence (NICE) (2009) is also currently reviewing evidence for its guideline, Depression in adults: treatment and management, which is scheduled for publication in 2020.