AS COMMON ANTIDEPRESSANTS ARE LINKED TO DEMENTIA... We should look at other ways to treat depression
ONE of the things I tell my students is that if you feel miserable that’s not mental illness. That’s life. We all have good days and bad days. Or look at it this way: you’ve had a bad day and then in the evening you go to the cinema and you get pleasure from it and it cheers you up. That’s normal. If you get no pleasure from it then you could be suffering from clinical depression. The inability to get pleasure from normally pleasurable activities is called anhedonia. And it’s an important marker for depression.
Our paper, recently published in the British Medical Journal, found that some commonly prescribed antidepressants known as anticholinergics may increase the risk of dementia and this will obviously increase concerns about the use of antidepressants. The study – one of the largest ever in this area – was funded by the Alzheimer’s Society.
We studied the GP records of 40,770 over-65s with dementia and 283,933 without, looking at their use of medication over two decades.
We found that certain medicines with significant anticholinergic activity appeared to increase the risk of dementia up to 20 years later.
THE risk increased the longer that patients took the medication and included certain anti-depressants with significant anticholinergic activity such as Amitriptyline and Paroxetine (tradename: Seroxat). These may account for a fifth of prescriptions for antidepressants. In total up to two million people in England are thought to be taking the medicines identified in the study.
At the other end of the age spectrum, figures released last year by NHS England under a Freedom of Information request showed that 64,765 under-18s were given medication to treat depression and anxiety between April 2015 and March 2016. This included 3,876 seven to 12-years-olds and 315 aged six years or under – though in the vast majority of cases young people are not usually prescribed the drugs mentioned in our study. Recently we – as a society – have generally become much more open about mental illness which is all to the good. In the past men in particular have been reluctant to discuss mental illness. But we need to reduce the stigma and accept that mental health affects us all. Most of us at some point will cross the line from being mentally well to not so well.
Twenty years ago it’s certainly true that antidepressants were over-prescribed. But now the guidelines have changed and antidepressants should generally only be prescribed for moderate to severe depression.
Antidepressants can literally be life-saving for more severe depression. But they usually need to be combined with other things such as talking therapies (eg cognitive behavioural therapy), measures to improve sleep pattern and encouraging patients to take more exercise.
Personally if I was a patient I’d be inclined to go for talking therapies and exercise for mild depression. Selective Serotonin Re-uptake Inhibitors (SSRI), the medicines that are commonly used, are not free of side effects. These potentially include sexual dysfunction along with an increase in agitation, confusion and lethargy. Some of these mimic the effects of depression itself so… it’s complicated. Depression is also a somewhat subjective diagnosis, there is no blood test for depression.
An even bigger issue with the use of medicines of all kinds is how you stop them when they are no longer helpful, known as “de-prescribing”. There has been a huge increase in the number of people over 65 taking many different medicines.
Another paper that I have published has shown that over 20 years the number of older people taking five or more medicines has quadrupled from one in eight to nearly one in two. For older people five is the new normal in terms of medication.
Chris Fox is a Professor of Psychiatry at the University of East Anglia, who also worked on the study and he says that too many doctors, pharmacists and nurses think “let’s not rock the boat” and leave people on medicines for longer than they need to be.
WE need to be careful about prescribing antidepressants across the age range. Old people are more likely to experience side effects and evidence suggests that antidepressants aren’t very effective for depression if you also have dementia. We need to be concerned about prescribing to children and young people because the brain is still developing.
With medicines you should weigh up the risks versus the benefits. You have to ask yourself: does this patient really need this drug? Is there an alternative? All medicines have side effects and should only be prescribed if the benefits clearly outweigh the risks.
Policy-makers need to look at this study and I hope there will be a realisation that we really need to use anticholinergics more carefully, particularly in older people. For depression, medication is only part of the treatment: a pill in itself won’t solve underlying problems that might have caused the depression such as redundancy or bereavement.
Successful treatment of depression needs a holistic approach involving both medication and talking therapies.
‘Medication is only part of the treatment’